4.2 Human resources
4.2.1 Health workforce trends
The level of human resources in health care is a matter of frequent discussions and controversies, partly because of past shortages and partly because of the segments of health care where workloads are higher. Obviously the first point is a reflection of the planning patterns or their inadequacy, while the second is a result of the organizational aspects of health care. Generally speaking, current policy goals are directed towards maintaining the present staffing of health care. There are also some challenges with respect to the geographical distribution of medical doctors. Intense efforts to secure an adequate number of medical doctors in the first decade of the 21st century resulted in significant increases. This fact, coupled with the impact of the financial crisis since 2009, caused temporary surpluses of medical doctors, and unemployment has been on the rise again. In October 2015, there were 53 registered unemployed medical doctors (State Employment Office, 2015). There is no evidence available to assess how Slovenia’s accession to the EU changed cross-border movement of physicians. However, the available statistical data and data from the Medical Register held by the Medical Chamber suggest that most immigrant medical doctors come from areas of former Yugoslavia and the rest of south-eastern Europe.
Fig4.5 presents trends in the number of physicians in Slovenia and some selected countries. In Slovenia, health policy since the late 1990s has translated into a steady growth in the number of physicians, from 2.19 per 1000 population in 1998 to 2.63 in 2013 (EU average is 3.5) (WHO Regional Office for Europe, 2015a). Two major factors influenced this change.
- The Medical Faculty at the University of Ljubljana increased its number of admissions and graduates, and another Medical Faculty at the University of Maribor was opened in 2003.
- There was a higher level of immigration from other parts of former Yugoslavia.
Despite this, Slovenia still has by far the lowest number of physicians per capita among the selected countries shown in Fig4.5 and the number is significantly lower than most EU and CEE countries (see also Fig4.7 below).
Fig4.6 shows trends in the number of nurses in Slovenia and selected countries. The issue of nurse numbers in Slovenia has two important facets. On the one hand, the Nursing Chamber does not agree with the current inclusion of nursing assistants (called health technicians) when officially counting the number of nursing professionals. According to the Chamber, the number should include only those nursing professionals who have successfully completed at least three years of study in post-secondary education (e.g. registered nurses). The Nursing Chamber, which represents both registered nurses and health technicians, also advocates that the ratio between registered nurses and health technicians, which is currently 35:65 in favour of the latter, should be reversed. This means that Slovenia would need to downsize the population of health technicians and introduce or educate another 7000 to 8000 registered nurses. Notwithstanding this dissonance about the number of nurses, Slovenia shows a high number of nursing professionals (both registered nurses and nursing assistants; 8.38 per 1000 population in 2013) when compared with Austria (8.03), Croatia (6.68), Estonia (6.48) and the average for the EU13 (6.22). On the other hand, the number of nurses in Slovenia is almost equal to the EU28 average of 8.49 per 1000 population. Nurses are considered to be key members of health care teams in outpatient settings, particularly in primary care, where their numbers are expected to rise further through the progress made in establishing “model practices” (i.e. having an additional 0.5 full-time equivalent registered nurses in the primary care team for preventive activities; see also section 5.3). In Slovenia, about one third of all nurses work in outpatient settings. Comparatively, the number of nurses working in hospitals is somewhat lower than in some, more hospital-oriented, health systems (NIPH, 2015b).
In Fig4.7, the number of physicians and nurses per 100 000 population is compared with other countries within and outside the EU. There were 263 physicians per 100 000 population in Slovenia in 2013, which was well below the EU15 average of 364 and the EU28 average of 347. In 2013, Slovenia had 833 nurses per 100 000 population, which was significantly below the EU15 average of 913 but closer to the EU28 average of 850.
The number of dentists in Slovenia has been increasing less rapidly over recent years, certainly at a slower pace than the number of physicians. The reason is that the number of students admitted to dental school remained much more stable, with fewer fluctuations from 2003 to 2011. A single increase of 12% was noted in 2003. There are no plans to increase the number of admissions at the University of Ljubljana, Department of Dentistry (part of the Medical Faculty).
As Fig4.8 shows, the number of dentists in Slovenia was 0.65 per 1000 population in 2013 which was slightly below the EU28 average of 0.67 per 1000, and significantly below that of countries such as Estonia (0.89), Sweden (0.80) and Finland (0.78). However, it was higher than the average for the Netherlands (0.52), Austria (0.57) and the EU13 (0.57). In Slovenia, workforce policies regarding the number of dentists are cautious because the final decision on how dental services for adults are to be reimbursed in the future is yet to be made (i.e. these services might depend more on OOP payments and private insurance).
The number of pharmacists in Slovenia has increased steadily since the late 1990s. However, as Fig4.9 shows, the number of pharmacists per 1000 population (0.58) in Slovenia in 2013 was significantly below the EU28 average of 0.82 and also below that for countries such as Finland (1.26), Croatia (0.70) and Austria (0.69). This is most likely the result of a rather conservative approach to planning and controlling pharmacist posts in pharmacies. However, the number of pharmacists working in pharmacies has been difficult to sustain as there is a well developed national pharmaceutical industry, supplemented by a relatively dense network of foreign pharmaceutical companies operating in the country. Career preferences for many students and graduates of pharmacy are, therefore, linked to the industry and its representative offices, rather than to community pharmacies. The industry continues to employ about one third of all professionally active pharmacists in Slovenia. In 2000, with the adoption of the National Health Plan, a more generous set of criteria and standards for the geographical distribution of pharmacies and pharmacists was adopted. This led to a gradual and slow – but sustained – increase in the number of pharmacists working in pharmacies. Slovenia has only one faculty of pharmacy, which is at the University of Ljubljana and was established in 1961. Contrary to the situations described for physicians and dentists, planning of pharmacy student numbers has been more efficient in terms of a timely increase in the number of students, which managed to prevent shortages of pharmacists. The number of pharmacists, even if lower than in other countries (see Fig4.9), is well balanced.
4.2.2 Professional mobility of health workers
Historically, under the Socialist Federal Republic of Yugoslavia, Slovenia was the only republic that had a strict numerus clausus system for the health workforce (operating since 1961). After that, the increase in the country’s provider capacity overcame domestic deficits through movements of medical and dental graduates from other republics. After 1991, this movement was stopped because of the new regulations set up by the newly established Slovene State and by the wars in other areas of the former Republic of Yugoslavia. These changes resulted in graduates that had moved to Slovenia prior to 1991 now being counted as foreign graduates.
After Slovenia’s accession to the EU in 2004, more mobility was expected from the broader CEE area but that never materialized (Albreht, 2011). Although salaries were increased significantly in 1996, 2000 and 2008, there were not many other incentives for cross-border mobility on a more considerable scale. Before the financial crisis (pre-2008), Slovenia used to be a destination country for cross-border movement of health professionals, mainly medical doctors and dentists from the area of former Yugoslavia and the Balkan countries. As domestic shortages are increasingly being resolved and with the freezing of salaries through austerity measures, the potential for emigration of health professionals has increased again but there have not been any recent published reports showing any important trends in emigration.
4.2.3 Training of health workers
Basic education leading to a university degree conferring the title of medical doctor takes six years. After graduation from the Medical Faculty, there is an obligatory six-month internship, which until 2007 had been extended into an obligatory semi-structured 18-month postgraduate training programme called “secundariate”. In January 2007 the secundariate was abolished and young physicians now enter postgraduate medical specialist training directly after their internship through open public tenders for specialty training posts, organized by the Medical Chamber. The number of training posts for medical specialists is reviewed by the Ministry of Health and then approved. These numbers are then presented to the HIIS, which is the institution that finances in full all medical specialist training posts in the public system. This system was intended to guarantee free choice for medical doctors in training without tying them too strongly to a specific provider, which had been the case previously.
Competence for preparing and implementing the programme of medical specializations lies with the Medical Chamber. The Chamber prepares lists of qualified tutors, health care providers and institutions where training can take place. Alongside this, there are also coordinators for each of the specialties who supervise both the tutors and the registered training institutions. During the course of training, tutors should monitor candidates. The examination commission at the Medical Chamber conducts the final examination and issues certificates. Tenders occur twice a year in which specialist training posts are offered to junior doctors. Posts are offered by specialty and by region. Candidates may apply for different specialties but can eventually only qualify for one post. Ranking is based on previous work, references and points obtained, based on additional activities (research, recommendation by tutors, additional courses, and so on).
Training in nursing is provided through post-secondary courses, offered as three-year programmes at the first level of the Bologna Process (European Commission, 2016c). Additional training is required for community nurses. There are various second-level Bologna programmes for masters’ degrees in nursing. There are eight higher education institutions for health professionals that provide university- or college-level training for nurses: the University of Ljubljana, the University of Maribor, the University of Primorska, the College of Nursing in Jesenice, the College of Nursing in Novo Mesto, the College of Nursing in Slovenj Gradec, the College of Nursing in Celje and the College of Nursing in Murska Sobota. The three last institutions do not have a concession and have only part-time educational programmes. This means that the three colleges do not receive public funds to carry out their educational programmes but instead have funded themselves from private funds, such as admission and teaching fees. The new curriculum for nurses, which started in 1993 at the University of Ljubljana, is based on the principles of primary health care, with a strong emphasis on health promotion and prevention, and includes health education as a course of instruction. There are several study pathways (beyond the nursing profession), namely general nursing, health education, midwifery, physiotherapy, occupational therapy, sanitary engineering, and orthotics and prosthetics. Graduates obtain bachelor degrees in nursing, midwifery, physiotherapy, occupational therapy or sanitary engineering.
Educational standards are set by universities. After a temporary suspension between 2012 and 2015, the Nursing Chamber recently regained authorization for the registration/licensing of nurses and for revalidation of qualifications through continuous professional education (see section 2.8.3). Nursing and midwifery are also two of the regulated professions within the EU.
Basic education leading to a university degree conferring the title of doctor of dental medicine takes six years. After graduation from the Medical Faculty there is an obligatory 12-month internship, which also serves to complete the obligatory postgraduate training period. Between 2000 and 2005, a process of restructuring of postgraduate specialist training was carried out. Since 2005, there are six dental specialties available to doctors of dental medicine.
Since 2015, the Medical Chamber has been responsible for setting the standards for postgraduate training for dental specializations and for continuous medical education. Doctors of dental medicine have to undergo similar procedures as medical doctors in order to obtain their dental specialty training.
The basic education leading to a university degree in pharmacy takes five and a half years. Pharmacists have two distinct pathways after graduation (section 2.8.3 has more details on this and on postgraduate training).
Public health specialists
Undergraduate training in public health is limited to the modest introduction received by medical, pharmaceutical and nursing students. An exemption is the Programme for Public Health for health inspectors.
The Medical Faculty at the University of Ljubljana has a Department of Public Health and the Medical Faculty in Maribor has two public health-related departments. The Department of Public Health in Ljubljana offers (in collaboration with the NIPH) various programmes for professional and research training (in particular, a one-year compulsory course for all future public health medicine specialists) as well as doctorate studies in public health.
In 2002, a public health medical specialty was introduced, which replaced the former three medical specialty training programmes in epidemiology, hygiene and social medicine. Specialization in public health takes four years of training. There are also training programmes (of two semesters; 400 hours of postgraduate courses) in social medicine; occupational medicine; health care for children, teenagers and women; and dental public health.
4.2.4 Doctors’ career paths
Medical doctors start their career paths by entering into a six-month internship. This is organized as a work placement in intensive medicine, with three rotations in internal medicine, general surgery and traumatology and anaesthesiology. The internship is financed by the state budget and at the same level for all interns. After this, they are required to take the state registration examination, proving their knowledge in intensive medicine.
Since 2007, running an independent medical practice requires a successfully completed period of specialty training. There are no exceptions to this rule and medical doctors without a specialty can only work under supervision of a tutor or their head of practice. Specialty training ends with practical, written and oral examinations, which are taken in front of a committee of three members pertinent to the specialty. Successful completion of the specialty training leads to the doctors’ first licence, which entitles the physician to practise independently without supervision. In public provider institutions, further career advances are from then on regulated by the Civil Servants Act (2002, amended in 2008), and in particular by one section describing a special category of physicians and dentists, which allocates all employed professionals of this type a position within a number of ranked classes. This system was implemented at the end of 2008 and is still in force. However, as part of larger austerity measures, advancement in the career rank classes was frozen by the Balancing of Public Finance Act 2011. This will change as some of the provisions of the Act are being softened (in 2015) and advancements will again be possible, in the first instance for those civil servants who should have had their advancements granted in the past three and a half years.
In a primary health care setting, a physician can become chief of a service (e.g. a GP) or a director. In hospitals, a physician can advance in positions from junior specialist to senior specialist, head of ward, head of department and director. The supervising superior is responsible for a physician’s evaluation every three years and can propose a regular promotion (one class) or extraordinary promotion (two classes). Promotions are based on the evaluation by the direct superior, but in public health care institutions these always depend on the approval of the director, who is independent in terms of this decision-making. Overall, most doctors usually stay within the institution at which their careers started. This used to be a mandatory requirement, since it was the employer who financed the period of specialty training and physicians were expected (bound by their contract) to remain employed there at least for the same period as their training had been after their examinations. The situation changed in 2009 when a central budget for the financing of specialty training was introduced, with funding provided by the HIIS and managed by the Medical Chamber. This meant that newly qualified medical specialists were only committed to the region where they trained but not to a specific provider.
Academic careers start with the post of teaching assistant, through to assistant professor (“docent”) and associate professor and then to a full professorship. Academic assistants (junior professors) must complete their master of science degree in three years and their doctorate in nine years in order to continue to be eligible for a post.
Slovenia maintains two types of professionals in nursing care - one type are graduated registered nurses, who completed tertiary education in nursing and the other type are nurses with a vocational education, also called nursing technicians. It is important to stress that the latter are twice as numerous. Education in nursing started its reform and significant transformation in the late 1980s and early 1990s, when there had been an increasing interest for a more Anglo-Saxon and Nordic approach to education in nursing. Consequently, the duration of nursing studies were extended and enriched. Vocational education in nursing did not change significantly, apart from some shortening of practical skills training. Overall, all the vocational schools remained in place. After the implementation of the Directive on regulated health professions, the Nursing Chamber started demanding that there should be a clear delimitation of the competences between registered and vocational nurses, the latter remaining with a much more limited scope of work, regardless of their experience. Additionally, the Nursing Chamber believes that the ratio in numbers of the two professional groups should be inversed and that in the future as an objective there should be 80% of registered nurses and only 20% of nursing technicians.
The issue of the recognition of the nursing competencies and the delimitation between registered nurses and nursing technicians had been presented to the MoH already in 2017 and no decision had been taken. Hesitation was likely because there had been no clear transition period proposed and that the future role of nursing technicians was not explicitly defined. The Nursing Chamber renewed its appeal to Minister of Health, Mr Aleš Šabeder in May 2019 to sign an act that would enact these competences.
Content of the reform
The Act came into force on 1 September 2019 and caused a lot of commotion. As mentioned above the delimitation of the competences mainly focused on relieving nursing technicians of many practical procedures and interventions, for which they previously gained practical experiences. The only exception would be nursing technicians, who obtained a supplementary license to deliver these services and perform procedures. However, there licenses are limited to the specific service cf. specialty they work in. Consequently, vocational nurses all of a sudden could not perform certain procedures, in a situation where there is a shortage of registered nurses and, in some cases, where the latter have insufficient practical knowledge. The trade union of the employees in health care (whose membership is predominantly from nursing staff), some hospitals and the Medical Chamber demanded that the Minister pulls the Act back. The Medical Chamber went even a step further and more politically demanded that the Minister of Health stepped down. The Minister responded that he acted in good faith and that he trusted the professionalism and responsibility of the Nursing Chamber. Eventually, under a lot of pressure from the public the Minister decided retract the Act and seek a compromise with the Nursing Chamber, hospitals and trade unions.
This situation revealed once again the lack of a consistent long-term strategy on human resources for health in Slovenia, which is essential for stable provision and development of the health care system in Slovenia.
Ažman M, Prestor J. Poklicne kompetence in aktivnosti izvajalcev v dejavnosti zdravstvene nege [Professional competences and activities of providers in nursing care]. Zbornica zdravstvene in babiške nege Slovenije- Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije Ljubljana, May 2018.
In July 2017, the Slovenian Parliament adopted the new Medical Services Act that reforms the current system of postgraduate medical specialist training in addressing its current flaws. Since 2007, specialty medical training is obligatory for all medical doctors but public tenders for training posts only occur twice a year. As a result, junior doctors often have to formally register as unemployed to maintain social security status before entering specialty training. There is also a high level of fluctuation across specialties (15% changed in the first two years) as junior doctors lack sufficient clinical experience for making the right choice. A further controversial topic in health policy is the financing of medical specialist training posts.
In light of these challenges the Government had committed to change the structure of the postgraduate medical specialist training including its financing and the role of the Medical Chamber with the stated objective to adapt the training to current needs and to increase the number of general practioners and paediatricians.
Content of the reform
The new Act extends the six-month internship after medical university training (called “secundariate”) to a one-year internship consisting of six months structured internship in emergency medicine and six months training under supervision. The latter can be recognized as rotation period for the subsequent medical specialty training. The prolonged training period allows graduates to make a more informed choice.
The Act also advances the moment when medical doctors can fully practice as personal primary physician (GP, paediatrician or gynaecologist). Previously, specialty training had to be completed to obtain a license to practice as chosen personal doctor in primary care. With the new regulation, doctors in speciality training will now be able to have patients enrolled once they have accomplished the rotations in emergency and intensive medicine (usually in their 3rd or 4th year of specialty training).
The responsibility of financing of postgraduate medical specialist training posts will be transferred from the Health Insurance Institute of Slovenia (HIIS) to the National Budget. This transfer will be gradual with a 25% annual budget increase between 2017 and 2020.
The Medical Chamber’s exclusive role in workforce planning and designing tenders for specialty training posts was considered too autonomous lacking public control over the definition of the number of posts. Formally, the Ministry of Health had the final say by giving the consent to the number of posts to be tendered, but, in reality, this was just a formality. The new procedure will still involve the Medical Chamber as key partner but also include other key stakeholders (Association of Public Providers of Health Services, National Institute of Public Health) in the final decision. The first tender based on this process was published in December 2017.