5. Provision of services
ollowing major restructuring in 2012, all public health services are now provided by two national bodies: the NIPH and the NLHEF.
Primary care is provided mostly by a network of community-level primary health care centres, owned and managed by municipalities; this covers around 76% of physicians and 42% of dentists working in primary care. They provide general practice/family medicine services; emergency medical aid; health care for women, children and teenagers; community nursing; laboratory and other diagnostic facilities; preventive and curative dental care for children and adults; and physiotherapy. There are also contracted, office-based physicians in private practice, many of whom have contracts (concessions) with the HIIS to deliver publicly funded primary care services.
Patients are entitled to choose their own personal physician operating at the primary care level. Since 2011, a system of family medicine “model practices” have been in operation via public health care centres and contracted group practices, with a focus on prevention and care coordination for patients with stable chronic diseases. It is the government’s intention that all practices adopt this model within the next few years.
Slovenia operates a gatekeeping system whereby patients require a referral from their primary care doctor in order to access specialist care. Specialist outpatient activities at the secondary care level are performed in public and private hospitals, primary health care centres, private specialist practices and spas. Clinics and specialized institutes provide more complex health services at the tertiary care level. Despite past efforts, long waiting times for some specialist services persist.
Inpatient hospital care is provided through a total of 30 mainly public and some private hospitals: 10 general hospitals, 2 university hospitals, 5 mental health hospitals and 13 specialized hospitals (three of them private). Of these, some highly specialized institutions provide tertiary care, such as the university hospitals in Ljubljana and Maribor, the Institute of Oncology, the University Clinic of Respiratory and Allergic Diseases Golnik, the Psychiatric Clinic Ljubljana and the University Rehabilitation Institute.
Since 2010, financial incentives have been in place to replace inpatient care with day care or ambulatory care. This has accelerated the steady rise in the proportion of day-care cases, from 11.1% of all hospital cases in 2005 to 30% in 2013 (with approximately 25% of all cases in acute care being day cases).
There is no single, overarching regulation concerning long-term care specifically. Such care (for the elderly, the chronically ill, the disabled and other individuals with special needs) is provided through different routes across the health, social care and pension and disability sectors, with different entry points and different procedures concerning the assessment of entitlements for supplements to support long-term care needs. As a consequence, some service users might end up benefiting more from current arrangements in place than others, or their needs might remain unrecognized altogether.
5.1 Public health
5.1.1 Organization of public health functions
Prior to 2014, public health functions in Slovenia were primarily undertaken by the NIPH and its nine regional institutes of public health. Since the early 1990s the NIPH has played a strong role in delivering public health initiatives, particularly in the case of health promotion and preventive programmes, with the regional institutes often finding alternative sources of public as well as private funding for these purposes. In 2012, the government proposed a major restructuring of the public health institutes through their mergers and simultaneous establishment of two new public health institutes at the national level: the NIPH and the NLHEF.
Since 1 January 2014, both the NIPH and the NLHEF have been fully operational, the former having its seat in Ljubljana and the latter in Maribor. For both, there is a regional structure secured by the establishment of regional units. In the case of the NIPH, these have been established in all nine locations of the former regional institutes of public health, while the NLHEF has seven regional units.
The role of the former Institute of Public Health was rather broadly defined in the Health Services Act of 1992, combining research, education and postgraduate training functions, covering all areas of public health. Traditionally, public health in Slovenia has had three main branches: social medicine, hygiene and epidemiology (of communicable diseases). Since the late 1980s, rapid development and integration of several fields led to the development of environmental health. Important components of all these fields (except for social medicine) have always been well equipped public health laboratories, some of them serving as reference laboratories. These now operate as part of the NLHEF. Three other important areas are covered by the NIPH through a set of small professional teams: health care organization, health economics and health informatics. The latter two are also built upon in several other institutions – particularly at the HIIS, which supports its own monitoring and accounting functions by a strong information system.
Another very important function of the NIPH is to maintain several important national health statistics databases, including the National Death Register, a hospital statistics database, an outpatient statistics database, a database of national health care providers and a database of health professionals. Additionally, the Ministry of Health decided in 2015 that it will place the Centre for Informatics in Health (including the Ministry of Health’s former eHealth Department of the Directorate General for Health Care) within the NIPH.
5.1.2 Communicable diseases control programmes
The immunization programme in Slovenia is rather extensive and some vaccinations are compulsory for children and adolescents:
- compulsory vaccinations for children 0–6 years of age: (1) diphtheria, tetanus, pertussis, Haemophilus influenza type b, poliomyelitis: vaccinations with three doses from 3 to 12 months of age and then the fourth dose in the second year of life; (2) measles, mumps and rubella (MMR vaccine): compulsory between 12 and 18 months of age;
- noncompulsory vaccinations for children 0–6 years of age: (1) pneumococcal vaccine is based on indications from the personal paediatrician and is reimbursed by the HIIS; (2) additional vaccinations for health or epidemiological indications, including tuberculosis, rabies, influenza, typhoid, meningococcal infections, hepatitis A and B, varicella (chicken pox) and respiratory syncytial virus;
- compulsory vaccinations for primary- and secondary-school children: (1) MMR vaccine (first year of elementary school); (2) hepatitis B; (3) diphtheria, tetanus and pertussis vaccine fifth dose in the third year of elementary school; (4) tetanus sixth dose for all children to the age of 18; (5) tick-borne encephalitis and rabies vaccinations for pupils and students who may be exposed to the diseases in practical training;
- noncompulsory vaccinations for primary- and secondary-school children: human papillomavirus vaccination for girls in the sixth year of elementary school;
- adults: (1) all adults have to be completely vaccinated against tetanus every 10 years and it is the responsibility of their GPs to keep track of these vaccinations; (2) all other vaccinations depend on the professional, training or accidental (voluntary or involuntary) exposure to a number of infections; (3) vaccine for influenza is recommended throughout life but it is partly subsidized only for those over 65 years of age or for those with chronic diseases.
Paediatricians are fully responsible for the vaccinations of children from 0 to 19 years of age and GPs are responsible thereafter. The National Immunization Programme and the Calendar of Vaccinations are prepared and updated annually by the NIPH.
Vaccination coverage rates are in slight decline but are still within the 95% recommended coverage by WHO for MMR (Table5.1). In 2015, there were vaccination promotion activities directed mostly towards parents concerned about the side-effects of vaccinations and who doubted the benefits of a large-scale vaccination programme. Coverage for human papillomavirus in girls is much smaller, even though it is reimbursed by the HIIS. However, since it is not compulsory, girls or, more frequently, their parents on their behalf, may decide against it. Controversies surrounding the initial phase of its introduction probably still contribute to the lower uptake levels. Coverage for the hepatitis B vaccine remains relatively high.
5.1.3 Screening programmes
Several screening programmes have been launched since 2000, including those for the early detection of cervical cancer (2001), risk factors for cardiovascular diseases (2002), breast cancer (2008) and colon cancer (2008). Apart from that, men over 50 are offered prostate specific antigen testing, which is not organized as a part of a systematic population screening programme but is reimbursed by the HIIS on demand from GPs who order the test for their patients.
5.1.4 Health promotion
In July 2008, parliamentary adoption of the National Health Plan for 2008–2013 (Republic of Slovenia, 2008) served as the basis for future action and development of public health, both at the conceptual and at the organizational level.
Several institutions are involved in health promotion. Since 2009, several initiatives, most notably by the Ministry of Health and the NIPH, have intended to strengthen this field. The reorganization of the NIPH also brought about the establishment of the Centre for the Management of Prevention Programmes and for Health Promotion as part of the NIPH, with the remit of designing, preparing and monitoring national prevention and screening programmes, including lifestyle changes. The Centre now effectively runs the national coordination of health-promoting programmes. This development occurred in parallel with the adoption of the first National Action Plan on Nutrition and Physical Activity, which has recently been adopted in a second edition. This effort serves – among several purposes – to collect improved data on the prevalence of chronic diseases and lifestyles in order to allow for more appropriate inputs into the planning of health promotion.
Health promotion and education programmes are also implemented at the primary health care level by nurses and other health care professionals working in primary health care centres. Programmes that have been established since the 1990s in cooperation with WHO – such as the Countrywide Integrated Noncommunicable Disease Intervention Programme and the Healthy Schools project – have become nationwide initiatives, although they operate at the level of local communities, cities and schools.
Furthermore, a new concept of GP practices was launched in 2011 (“model practices”) that should enhance their prevention activities and also support lifestyle changes, particularly improvements in patients with chronic conditions, thus fulfilling a secondary and tertiary prevention mission (see also section 5.3). Involvement of additional nursing support at 0.5 full-time equivalents means that patients who visit the practice receive a consultation with a specially trained nurse who assesses their current lifestyle, provides advice and/or receives feedback from patients who have already subscribed to a programme (e.g. weight loss, smoking cessation, alcohol cessation). In 2015, around 50% of GP practices had already developed these services and it is expected that over the following two years all GP practices will adopt them (funding permitting). Similar initiatives now exist for primary care paediatrics and primary care gynaecology, pending approval by the Health Council.
Some members of the Parliament (MPs) proposed a motion to delay the implementation of plain packaging for tobacco products, claiming that the time enacted in the respective Act was too short. They requested an open discussion at the Parliamentary Committee on Health demanding a three year extension so that plain packaging would be introduced only from 1 January 2023 instead of 2020. The disappointing fact was that the proposing MPs embraced entirely the arguments of tobacco industry claiming that the Act would damage Slovenia's public finance.
It was very impressive how in a special spin they were claiming two conflicting 'facts' – one that plain packaging had no effect on smoking prevalence and the other that state revenues from the excise taxes on tobacco would drop in value. Eventually, after a heated debate, the proposal was rejected at the Committee, based on an enormous evidence provided by the NIPH, NGOs active against tobacco and also statements publicly expressed by the leading WHO experts
The National Institute of Public Health (NIJZ) started the development of Centres for Health Education in 2003. Theses Centres offer workshops for persons with increased risk of NCDs alongside screening programme for detection of risk factors for CVDs. The workshops gradually developed into structured programmes for different population groups with increased risk for NCDs.
The NIJZ now aims to enhance these workshops in collaboration with other sectors at the municipal and local community levels by developing Centres for Health Promotion. These Centres for Health Promotion are open to all persons who want to improve their lifestyle and health status. Their activities aim to reduce inequalities in accessing screening and other organised programmes throughout the entire population and to prevent diseases. The first centres located within primary health care centres are already established and operating. Over the next 2 years up to 25 Centres for Health Promotion are to be opened.
The Slovenian Ministry of Health, together with WHO Europe and the National Institute of Public Health (NIJZ) decided to prepare a new public health strategy for Slovenia based on a comprehensive assessment of the 10 essential public health operations (EPHOs). The EPHOs provide a framework for the assesement of public health by mapping available public health instruments and tools with the ultimate aim to strengthen public health.
After previous unsuccessful attempts in developing a national public health strategy, the Ministry of Health decided to mobilise and involve a wide range of public health professionals and other stakeholders in assessing public health. This is being done through the use of the WHO online tool for the assessment of the EPHOs. The process started in September 2017 and is expected to lead to a draft strategy by July 2018.
On 15 July 2015, the Parliament adopted the Resolution on the National Programme on Nutrition and Health Enhancing Physical Activity 2015-2025. It aims at improving nutritional and physical activity of the population from early life through to old age. This would revert the trend of increasing obesity levels of the population of Slovenia that is particularly pronounced in lower-income and lower-educated populations.
The national programme aims at achieving the following strategic goals:
- Prevention of overweight;
- Reduce the share of the physically inactive population;
- Increase the share of breastfed infants;
- Decrease the share of malnourished and functionally disabled elderly and patients;
- Increase the share of those who regularly take breakfast;
- Increase the consumption of vegetables and fruits;
- Reduce the intake of saturated fats, sugars and salt;
- Reduce the presence of trans fatty acids in food.