Health Reform in Slovenia: From a Regional Success Story to Scolding by EU more

HEALTH REFORM IN SLOVENIA: FROM A REGIONAL SUCCESS STORY TO SCOLDING BY EU Tanja Ahlin, Heidelberg University In 2004, The Lancet published an article praising Slovenia¶s health system as the most effective in comparison with Slovenia¶s neighbours in Central and Eastern Europe (Aris 2004). The political and economic stability of this country of 2 million people enabled the implementation of reforms that have been so well received ³that the World Bank is translating it and intends distributing it to other transition countries as an example of how to tackle the funding problems´ (Aris 2004: 2146; Skiedar 2003). One of the main issues of the health reform in Slovenia has been the privatisation of health care which induced a transformation of the state-run system to a more decentralized one ( vab 1995). Historically, private practice existed in the region since the 19th century, with key institutions such as hospitals being state-owned; however, licences were suspended from 1957 until 1991 when Slovenia declared independence from Yugoslavia and the Medical Chamber of Slovenia was formed (Albreht & Klazinga 2009). The goal of privatization at the time was to introduce the concept of physicians as free professionals, increase efficiency, overcome the practice of informal payments, implement better managing, suppress financial losses and underinvestment, and enlarge funding (Albreht & Klazinga 2009: 263). This process, symbolic of the great changes in health policy throughout Europe at the time (Saltman & Figueras 1997; Deppe & Oreskovic 1996; Ritsatkis et al. 2000), was probably efficient since it was much slower than in other post-socialist countries in transition, such as Croatia, Macedonia, and Serbia where rapid privatization took place without much coherent and synchronized control (Voncina et al. 2006; Gjorgjev et al. 2006, Donev 1999). The main areas of the reform adopted in 1992 included the introduction of health insurance system of payment instead of budget financing, a new method of planning through negotiation between the Ministry of Health, the National Health Insurance Institute (NHII) and the Medical Chamber, and the introduction of independent practice (WHO 1999). The later is performed either as pure private practice, based on out-of-pocket payments, through a contract with NHII which provides for a relatively stable income, or a combination of both ( vab et al. 2001). By 2001, 10% of all physicians were thus self-employed, the main reasons for their decision being dissatisfaction with the organization within institutions where they previously worked and the possibility of greater income; they reported the most positive impact their decision had was the improvement of doctor-patient relationship (Kersnik 2000, vab et al. 2001). The changes in organization of health care and its other related aspects, such as the possibility of free choice of a family physician, were reported to be highly satisfactory for the consumers, too (Kersnik 2001). The structural changes, however, challenged the role and status of primary health care centres which found themselves at the cross road of the interests of Ministry of Health, NHII and the municipalities, holding both public and private competencies (Albreht, Delnoij & Klazinga 2006). In relation to the funding of the health system, Slovenia implemented a Bismarck-type of insurance system with a compulsory and a supplementary voluntary health insurance (Juren 1992, Albreht & Mo nik Drnov ek 1994). While the privatization of provision was more or less successful, the privatization of health care facilities or of health insurance was hindered by the lack of long-term health strategy and of consensus of social partners as well as undefined privatization of state property and no decision on public-private partnerships (Albreht & Klazinga 2008, 2009). The main sources of income for the health care budget, controlled by NHII, is thus the compulsory health insurance which is partly acquired by a percentage deduction from the wages of employees and other personal incomes and partly by direct payments by employers, providing over 80% of all health care funding (Kersnik 2001). The majority of Slovenian citizens are this insured through their employment status while the health care for the unemployed is covered by local communities. The compulsory insurance covers the basic services, but other services or drugs have to be paid for either out-of-pocket or through the voluntary insurance, obtained by 95% of Slovenians (Aris 2004). The problem of the latter, however, is that the premium is the same for everyone no matter their financial status, and people may contribute from 8% to as much as a 2 months¶ salary a year for health insurance (Aris 2004). The compulsory health insurance has also been found problematic by the European Commission which recently referred Slovenia to Court of Justice over the issue (Europa 2011). In response, the Ministry of Health published Health Care Upgrade by 2020 that envisions increasing solidarity through reducing the share of private expenditure in health care (currently at 26.9% of GDP) and enlarging the public share of public funds to at least 80% which would be possible by abolishing the complementary health insurance (Maru i 2011). Not surprisingly, this has resulted in strong opposition by the Slovenian Insurance Association (SIA 2011), suggesting that the demands of the European Commission could be satisfied without such important intervention into the complementary insurance scheme. Furthermore, due to a shortage of physicians, the procedure for accreditation of medical degrees was facilitated (Juren 2010). 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