Diagnoza slovenskega zdravstva
Is the Slovenian healthcare system really in crisis? This moment is facing so many problems that it seems as if there have never been so many before. This impression is certainly helped by the Fides union doctors’ strike, which mainly brings to the surface the dissatisfaction of doctors with salaries and working conditions on the one hand, and the dissatisfaction of users with services and queues on the other. Under the ballast of these everyday problems, the deeper causes of the crisis remain hidden, stemming from the structural damage of the entire society and the ossification of the health system, as it was designed decades ago and has barely adapted to new conditions.
Problems with accessibility to the health system, long waiting times, lack of doctors, systematic dissatisfaction of both users and providers of health services, as well as poor management and possibly inadequate financing of the health system, all these are just consequences of accumulated discrepancies that demand wider social coordination.
After all, in the last 25 years, our life expectancy has increased by 12 years, but, as doctors find out firsthand, we are not living longer for the years when we are healthy, but for the 12 years when we need even more medical care.
It happened to us, like everywhere in the developed world, the so-called silver tsunami. The growing number of elderly people with more chronic diseases, more exacerbations and more hospitalizations has overwhelmed our already overstretched health care system. The number of doctors identified per family doctor decreased and with this increased pressure on all other structures in health care, which caused overcrowding in emergency rooms, increased waiting times for ambulatory services and drove nurses to flee due to overload. There are fewer doctors than in most other countries of the Union, and they are also poorly distributed by specialty. A shortage of nurses threatens to close the doors of hospital wards that treat the sick or the elderly.
Even the basic issue that the health care system deals with, i.e. the issue of health, is in fact a social issue that is part of the general paradigm of time or civilization. According to the definition of the World Health Organization, health is not only the absence of disease, but also mental, physical, emotional and social comfort or well-being.
According to such thinking, health is a dynamic balance of physical, mental, emotional, spiritual, personal and social elements, which is manifested in the ability to continuously perform functions and adapt to the environment. In this sense, health and care for it are not only the interest of the individual, medicine and medical institutions, but the responsibility of the entire society.
The social community has placed this responsibility on the shoulders of medical institutions and doctors. The doctors themselves do not have much influence on how she will ensure that the doctors, together with the support services, can also fulfill this responsibility. Their job is to treat patients and take care of people’s health, and society should provide them with an adequate framework for this. But it cannot do this well without taking into account their experiences and thoughts.
And then we are users when we find ourselves in the system as patients. Some health experts warn that Slovenians are still used to getting everything for free in healthcare. Of course, regardless of what kind of attitude we have towards our health, which is a special chapter that we did not pay attention to due to the already too extensive problem. Even a jump across the border to Austria, experts say, shows how sensible it would be to introduce surcharges for services.
They would need some experience from abroad to know how to appreciate what they have at home. Across the pond, you have to pay a lot for insurance to be treated roughly as widely as here, otherwise you don’t have enough money to even pay for the basics. In Europe, most countries have public health care with various forms of insurance or financing, but there are long waiting times at emergency rooms everywhere. Even in Sweden. These facts should be repeatedly shown and described in our media as well, emphasizes one of our interlocutors.
The sense of crisis is also caused by the almost hostile stratification of the media into public institutions and concessionaires. Concessionaires are part of the public health system, and as such they should be treated equally. So we often hear and read platitudes about how they are only interested in making money, picking up trash, and maintaining “duplicity”. Too often we forget that the concessionaire himself must provide the facilities with which he will provide medical services, which also means investing in, for example, a hospital or polyclinic with all the necessary equipment. Such investments in public institutions are financed by the state or municipalities with taxpayers’ money.
At a time when the inevitable social debate is already flaring up about these topics, we turned to a few doctors and health managers, fellow travelers of the Institute Naprej, to complete the picture of the state of our health care from their point of view and through their thoughts. The answers, which we have summarized in this article, were sent to us by, among others: dr. Hugon Možina, head of Internal First Aid at UKC Ljubljana, which accepts the most seriously ill patients, Igor Rus, specialist in internal medicine at Jesenice General Hospital and Roman Ratkai, financial manager who has been managing Murska Sobota Hospital for the last year as director.
Although there is a prevailing impression among the public that the diagnosis of our healthcare is bad, our interlocutors, being clearly aware of the problem, also emphasize its good sides. Not all of the previously mentioned problems occur to the same or comparable extent with all contractors. We have hospitals that are in a good financial position, and medical workers from some hospitals do not run away to other activities or to concessionaires or even to private individuals. Likewise, some hospitals do not have problems with premises, financing, suppliers. The same can be said, experts say, for medical centers – last year only eight out of 61 medical centers operated at a loss – and they emphasize that the image of some kind of general crisis in healthcare is not realistic.
In total, all health care centers realized 750 million euros in revenue last year, and 18 million euros in excess of revenues over expenses (2.4 percent of revenues), according to the reports of ZZZS. On the other hand, 12 out of 27 hospitals operated at a loss. Hospitals realized 2.25 billion euros in revenue and 0.7 million euros in revenue deficit compared to expenses.
Hugon Možina, “Our health care is not necessarily in crisis, as it has excellent results in many areas. We are the best in the world in the field of heart transplantation and survival after it; among the best in the world in the treatment of acute coronary syndrome – after domestic heart attack, as we rank among the top nine countries in terms of survival rate; we are somewhere in the middle of the scale regarding the treatment of cardiac arrest – we were among the first to start immediate coronary angiography after the event, and survival depends on early defibrillation. Here we spread the use of the automatic heart defibrillator (AED) to less populated, remote parts of Slovenia and train the first providers of resuscitation: firefighters, policemen, villagers and others. In short, if we were to evaluate healthcare based on such criteria, we are even among the best.”
Roman Ratkai: “In general, our health care system works professionally and provides patients with professional, safe and high-quality care. With significantly less invested money, according to many indicators, Slovenia achieves the same or even better results than EU countries, which allocate more money to healthcare. But without decisive changes in the organization of its operation. In the long term, we will not be able to provide strong, solidary and fairly accessible public health care.”
Some other indicators, which are used to measure the success of the health system, or at least parts of it, which our interlocutors do not mention, show that Slovenia has good health care. We are also at the top in the field of obstetrics. In 2021, infant mortality was at the level of 1.8 deaths per 1,000 live births, which is significantly lower than the average of the most developed countries of the Union (2.8 deaths per 1,000 live births). ZZZS business reports.
If administrators, i.e. managers, and practitioners, i.e. doctors, are relatively unanimous regarding the good aspects of our healthcare, they differ more about the causes of the crisis. Understandable, as each side has its own issues with it; managers with management and contractors with operations, both in increasingly stressful conditions.
From the point of view of managers, the problem – in addition to their salaries – is, for example, the councils of institutes that supervise their operation, but they are extremely poorly stimulated for this work and are a surviving form of management that hinders the development of the health system, the development of the profession, and the rewarding of successful employees. ZZZS is also said to represent an outdated status form, which should radically change its organization and processes, especially in relation to the payment of health services.
In general, it is heard that healthcare is in crisis due to inadequate management, which is the result of the lack of common social goals in the field of healthcare, which every government is committed to realizing, and the too rapid change of responsible persons in leading positions in the country. Statistics confirm this, as they show that two key positions in our healthcare, i.e. the Minister of Health and the General Director of UKC Ljubljana, are replaced every 15 months on average. And since UKC Ljubljana is also in a constant crisis due to such personnel tsunamis, this affects the entire health care system, since the Ljubljana University Clinical Center represents almost a third of our health care system.
Roman Ratkai: “The lack of experts in individual fields, staff turnover, (un)competitiveness of employment in the health sector and difficulties in bridging intergenerational differences are the key challenges that practically all practitioners face today. The image of the situation that the media portrays to us is next: There is a shortage of personnel in healthcare in Slovenia; in general, there is none, but those who are, have to work in bad conditions with heavy workloads, lack of career opportunities and are poorly paid.
Contrary to popular belief, the statistics show a slightly different picture at first glance. The number of health workers (doctors and nursing workers) in public health institutions increased by six percent in 2023 compared to 2018 in hospitals, and by as much as 21 percent in health centers. The number of all doctors in hospitals increased by five percent in 2023 compared to 2018 (151 more employees), and in health centers by 17 percent (230 more employees). The problem, however, is that the number of employees in nursing in hospitals decreased by four percent during the same period, while in health centers it increased by 20 percent (771 more employees). The data on the implementation of the program also show that, compared to 2018, more services were provided in 2023. “
Roman Ratkai: “In addition to the lack of adequate financial and personnel resources, Slovenia is also characterized by a lack of vision and strategic planning of investments in healthcare. Facilities intended for healthcare activities were built in Slovenia in different periods from 1889 to 2009, so they are characterized by the lack of adequate spatial capacities in addition to their non-functionality, fragmentation and worn-out basic infrastructure that does not follow the needs of work processes and the technological development of medical professions.
The facilities are also energy inefficient, with high ongoing maintenance and energy costs, as well as high wear and tear and depreciation of equipment. As recently as 2011, the write-off rate of equipment in Slovenian hospitals was 67%, and in 2023 it will already be more than 85%.
The development of information and communication technologies and digital services is lagging behind – even compared to the average in the EU. Less than two percent of total revenues are allocated to information and communication technologies, while the economy allocates up to ten percent. The problem is also the disconnection of different information systems and the inability to exchange data due to non-harmonized standards, and thus the correctness of the data also becomes questionable.
From 2008 to 2022, an average of 37.2 million was invested annually in health infrastructure and medical equipment, which, given the size and age of the infrastructure and the development and progress of health care, is significantly insufficient for the long-term preservation and development of suitable health infrastructure. The law adopted in 2021 on the provision of funds for investments in healthcare therefore provided for as much as two billion investments from the domestic budget and European funds until 2031.
The law established the basis for systematic planning of short- and medium-term investments, especially for strengthening the already existing public health service network in such a way that projects will be planned and implemented in a coordinated, efficient and rational manner. Effective organization and appropriate work planning are the key to the timely and successful implementation of investment projects. The problem is that both the Ministry of Health and health service providers lack professionally qualified workers in order to be able to successfully and timely realize all the planned investment projects, which are extremely demanding and complex from an organizational and implementation point of view. The capacities of contractors on the market are also limited, especially if we take into account that foreign construction companies rarely apply for our tenders.”
Hugon Možina: “Some areas, which mean a lot to patients and families, are on foot or are not there at all: access to a family doctor in urban areas (Ljubljana, Maribor, Celje, rural areas are still regulated), palliative treatment and support at home in most health regions is not developed at all. There is no psychological support in moments of severe trauma, illness, or bereavement; it is only available at the Oncology Institute, access to important specialist treatments (e.g. cardiologist, rheumatologist) is poor. We practically do not have geriatrics. There are many reasons for the lack of certain profiles of doctors and nurses.
With 3.2 doctors per 1,000 inhabitants (including those who do not work with patients: teachers, those in the pharmaceutical industry, insurance companies, inspectorates, etc.), we are in the last quarter of the Union. Of course, this does not apply to all areas. In the last decade, there are the fewest doctors where there is more work and greater responsibility, but we have more of the same ones who deal with eyes, skin, physiotherapy, etc. There are around 7,000 active doctors in Slovenia. However, if we look at the share of family doctors, there are on average as many as 1,850 patients per doctor.
The effectiveness of doctors is also falling due to shrinking support teams. Several nurses switched to primary health care by opening referral clinics, now also Health Promotion Centers. With the change in legislation, family doctors are now offered barely half of a graduate nurse. This means an additional displacement of these health workers from already dysfunctional hospital wards. In Nursing Homes, there is much less night work for nurses, and they also do not have to be on duty during weekends. In the last few years, e-hospitals have already closed many patient rooms and discontinued several internal medicine departments due to a lack of nurses, and doctors are also leaving for other fields. The movement of nurses from hospitals to health centers will be new, and for some departments it will certainly be the last blow. You need a decade or more to restart a specialist department. When wards in regional hospitals close, the pressure on UKCs and on the remaining nurses increases, and this is a vicious cycle. This will result in an increased departure of young doctors abroad.
The burden of acute illnesses is being shifted from nursing homes to emergency medical aid departments and emergency centers, which cannot handle such a burden. Acute illness is rarely an emergency illness, or to put it another way: an ear infection is not for the emergency room. There are few specialists and specialists in emergency medicine – only a few still apply for specialization in emergency medicine – barely a fifth of the expressed needs, and with such an attitude we will stifle this activity. More seriously ill patients are mostly treated by internal medicine specialists in the emergency room. There are also fewer and fewer of these, even though this specialization is the most necessary, modern and efficient for the needs of the aging population. The management of chronic patients is transferred from health centers to targeted specialist outpatient clinics, thus lengthening waiting lines.
Igor Rus: “It is primarily a personnel crisis, which is conditioned by a social crisis of values in our society. It is also a matter of misunderstanding of the status of employees, misunderstanding of the functioning of healthcare and its processes on the part of decision-makers, the problem of facing an aging population, the gap between the possibility of a functioning system with current personnel resources and the needs of patients.
The equipment is partially outdated, the problem of public tenders is already chronic, we are witnessing the complete collapse of the Department of Investments at the Ministry of Health, which still has not determined the location for the new hospital in Gorenje, although European funds from the title of recovery have already been secured. A completely apathetic and dysfunctional Ministry of Health is an integral part of our health crisis.”
Funding is probably not as big a problem as providing adequate professional and support staff. The state can quickly regulate it by changing the legislation, which would enable additional budget financing or the redistribution of budget funds and the introduction of co-financing of certain services or works.
According to many, financing became problematic after the abolition of supplementary health insurance; thus, this year, for the financial sustainability of ZZZS, the latter must transfer 400 million euros to the budget. In 2027, due to the aging of the population and smaller inflows, the amount from the budget will already be one billion euros. With all this funding, ZZZS is not an insurance company that finances health, but treatment. And since all this is covered by budget funds, there is no real interest in health financing. The health insurance company already provides more than 600 million euros for patient stocks.
Igor Rus: “With the existing funds, we will be able to maintain the level of patient rights for some time, although we will probably have to start talking about the basket of guaranteed rights, and the problem is closing departments due to lack of staff.” The Gorenjska region has lost over 100 internist beds in the last five years alone, the ‘flow’ of patients on the existing beds has increased significantly; which, of course, also comes at the expense of quality treatment, as a result of which the remaining staff who are still persisting are overburdened.”
Roman Ratkai: “The fact is that in recent years, compared to the period before the epidemic, significantly more financial resources have been allocated to health care for the implementation of health programs and the financing of investments, cumulatively more services have been provided and more personnel have been employed, but there are still problems with accessibility remain present. However, the health care system works from a professional perspective and provides patients with professional, safe and high-quality care.”
The already mentioned options for additional budget financing and probably also additional public and private insurance and the creation of a basket of services are only one area of action. Perhaps even more important is the establishment of fundamental, common social goals that would be committed to the realization of each of the governments that alternate in power.
Hugon Možina: “The state and society must say which doctors we need more, they must plan the health network and provide additional financial support to those specialists who are in short supply. It is necessary to reward the profiles that we need and will cope with the aforementioned tsunami: family doctors, internists, geriatricians, those who deal with palliative medicine, etc. In this way, these specializations will become more interesting, more competitive with classical acquisitions. It’s the same with nurses. There is a need to better reward nurses in those places where there is a shortage. These are usually areas that are more labor-intensive and require greater responsibility.”
Igor Rus: “It is necessary to change the organization of medical institutions according to business companies, and politics must be removed from supervisory functions; it is necessary to appoint competent management and fully empower them and reward them accordingly.. The current salary of the director of UKC Ljubljana, an institution with a budget of 700 million euros, is 3500 euros, which places him somewhere in the 50th place within UKC.
Already in the education process, it is necessary to take care of suitable personnel, their better remuneration, employment of nursing personnel from abroad in particular. And with regard to patients, it will probably be necessary to start talking about the basket of guaranteed rights, and for the rest, additional insurance will have to be activated, while it is necessary to legally protect more vulnerable groups.”
Roman Ratkai: “Changes are needed in the operation and management of healthcare providers as institutions, because this is an outdated normative arrangement. It is necessary to increase the powers of directors, introduce remuneration, individual contracts with key employees, and abolish the management system. increase salaries and at the same time reduce the number of days off from annual leave, training, days off after duty and in this way reduce the shortage of medical personnel. The public-private relationship must be regulated; we urgently need both genders, and to establish the same conditions for both, which means that the system must not result in private healthcare providing only well-paid services (radiology, orthopedics…), while public healthcare is left with complex and poorly paid cases. It is necessary to compare the effectiveness of work in private and public institutions. The computerization of work processes must also be increased.”
We often hear that being a doctor means fully living the mission of a doctor. Medical doctors were raised and trained in this spirit. Many take it for granted that they are in this job 24 hours a day, every day, and nothing is too difficult for them, regardless of the length of the work. However, the situation is changing in this area as well…
Hugon Možina: “The feeling of a doctor depends on which coast he is fighting a tsunami on. Some people don’t even get their socks wet. In any case, successful professional work is universally important for well-being, the awareness that your efforts have been noticed – there is no such thing, you read and listen to scoldings, insults and insults – support of the team, family, enough free time, sports, especially friends, reading, other hobbies , canine friends… In the USA, they constantly monitor this area and note that those who work in the emergency room like to resort to adrenaline sports. When everything is too much and you are already in dire straits, only a short-term withdrawal from the environment helps.”
Igor Rus: “The older employees still feel a certain responsibility towards the profession, which is also our mission, but unfortunately this is no longer the case with our younger colleagues. There are no more applications for certain advertised specializations, nursing graduates prefer to be employed in service activities… At the micro level, things are still going on, but for how long?”
Author: Brane Maselj
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