I. THE WAY WE LIVE
5.1 Access to health care
5.1.1 Health care resources
Slovenia lags behind the European average in indicators of health personnel. Due to the fast-growing demand
23 Communication from the Commission. Implementing the Community Lisbon Programme: Social services of general interest in the European Union, Brussels, 26 April 2006.
The modernisation of social and health services lies at the heart of contemporary European policies.
for health services, which is the result of rising income, advances in medicine and medical technology, awareness of the importance of health and the ageing of the population,
most European countries face a lack of physicians and nurses. In Slovenia the ratio of practising physicians to 100,000 inhabitants is worse than in the majority of EU countries: in 2007, Slovenia had 24724 practising physicians per 100,000 inhabitants, compared to the EU average of 326. The number of practising physicians in Slovenia increased by an average of only 1.4% a year in the period 1996–2006, whereas the average increase in the EU was 2.4%. In recent years (2001–2006) growth in the number of practising physicians picked up, to an average of 1.7% a year. Analysis by the Institute of Public Health (IVZ) shows a particularly pressing lack of physicians at primary level in some parts of the country, and a general shortage of paediatricians.25 According to staffing projections,26 the number of doctors should increase by 11.4% in the period 2008–2013. The number of dentists reached 62.8 per 100,000 inhabitants in 2007, Slovenia is at the bottom of EU rankings on number of doctors per 100,000 inhabitants, on a par with the EU average on number of dentists and above the EU average on number of nurses.
24 According to data by the Institute of Public Health of the RS (IVZ), there were 4,981 practising physicians in Slovenia in 2007 (this includes specialists, interns and trainees).
25 Estimate of the Institute of Public Health of the RS (IVZ) based on HIIS data on policy holders who have selected their personal physicians (IVZ, 2006).
26 Resolution on a National Plan of Health Care 2008–2013 (OGRS, No. 72/08). Projections account for the demographics of physicians (graduates, retirement, emigration, immigration, death rate and retrospective trends).
Figure 17: Number of practising physicians per 100,000 inhabitants in 2006 and average annual rate of growth in the number of practising physicians in the period 1996–2006, EU-27
-1 0 1 2 3 4 5 6
0 100 200 300 400 500 600 700
Greece Belgium Malta EU average Bulgaria Austria Lithuania Italy Spain Sweden Czech R. Germany France Estonia Denmark Slovakia Hungary Ireland Latvia Luxembo… Finland Cyprus Portugal Slovenia U. Kingdom Poland Romania %
Number
No. of practicing physicians per 100,000 inhabitants (left axis) Average annual growth, in % (right axis)
Source: Eurostat, 2008 and WHO Database, 2007; calculations by IMAD.
which is around the EU-27 average. At present, over a fifth of all health insurance policy-holders do not have a selected dentist. Projections until 2013 suggest that the situation will get worse as dentists retire but not enough graduates replace them. The number of nurses reached 791 per 100,000 inhabitants in 2007, which is relatively favourable compared to other European countries (EU in 2005: 736). However, the share of nurses with higher education is much lower than in other European countries, although it has been increasing rapidly over the last few years.
The per-capita number of hospital beds continues to drop rapidly in Slovenia even though a comparison with European countries shows that capacity is already relatively low. In 2007, Slovenia had 466 hospital beds per 100,000 inhabitants27 (2006: 476), whereas the EU average was 590 in 2005. For years, this trend has been underpinned by shorter average length of hospital stays and the expansion of outpatient treatment. However, in the 2000–2006 period, the number of hospital beds per 100,000 inhabitants plunged by 15.6% whereas in the EU it dropped by just under a tenth in the 2000–2005 period.
Waiting lines for acute and non-acute treatment were reduced slightly following the introduction of a new financing model: since
2003, acute hospital treatment has been paid based on diagnosis-related groups and 2004 saw the introduction of a model for payment
of non-acute inpatient treatment on the basis of bed days. The new models improved the quality of data which form the basis for the disbursement of funds in the acute inpatient treatment programme, changed the definitions of programmes and their restructuring, and provided ongoing monitoring of financial savings on individual programmes. According to a study (Ceglar and Marušič, 2007), the number of acutely treated patients rose by a tenth in the 2003–2006 period and the scope of the realised programme in non-acute treatment by as much as 256%. The number of patients waiting for acute treatment dropped by nearly a fifth between 2003 and 2006. The average length of hospital stay also continued to drop, falling by 9% in this period. This improved the cost efficiency of providers as it reduced the losses of hospitals.
According to the Health Insurance Institute (HII) data, the share of private providers among general practitioners rose to over a quarter (26.8%) by 2007. In 2007, there were 1,262 private providers with a concession (doctors and dentists) and 192 without a concession. The share of private general practitioners (paediatricians excluded)
27 Data refer to the number of all hospital beds (not only acute) and include the Diagnostic Centre Bled and MC Medicor (IVZ).
increased most, from 18.7% in 2005 to 25.1% in 2007. The increasing share of private practitioners is a consequence of the falling number of
practitioners in public institutions as well as the rising number of private practitioners. Last year, the number of private specialists in particular increased more than in
the previous years: the share of private practitioners among all specialists rose from 9.8% in 2006 to 11.3%
in 2007.28 The number of private providers without a licence (192) has increased by 20 since 2002 (most work in dental medicine), which indicates that Slovenia does not offer appropriate opportunities for the expansion of purely private health care provision. Data by the HII also indicate that private practice has been expanding in the public health care network over the recent years.
The number of contracts with private providers rose by 110 between 2006 and 2007, whereas the average annual increase was 46 in the 2000–2004 period. Private providers accounted for 13.1% of expenditure on health programmes in 2007. This share has jumped by 4.5 p.p.
in the last five years. The expansion of private health care provision was expected to have a positive impact on the accessibility of health services, competition and the efficiency of providers. But if concessions continue to be granted without the existence of a defined network of public health care providers – which would help determine where in the country concessionaires are indeed needed – and given the lack of an appropriate system that would make the granting of concessions transparent, access to health care services at the primary and secondary levels could be jeopardised.
5.1.2 Expenditure on health
Slovenia’s expenditure on health as a share of GDP is slightly above the EU-27 average. Total expenditure on health amounted to 8.3% of GDP29 in 2006, compared to 8.2% for the EU-27. In 2006, a total of 13 EU-27 countries had higher health expenditure than Slovenia.
Between 2001 and 2006, the average annual increase in total health expenditure
in Slovenia was 3.2%, which is substantially below average annual GDP growth (4.3%). In this In 2006 and 2007, the
awar-ding of concessions in the public health care network accelerated, but there are still few private practitioners without a concession.
If the awarding of concessions continues in the absence of a defined network of public health care providers, access to health services at primary and secondary level may worsen.
28 Data by the Medical Chamber of Slovenia show the number of doctors as it is (including interns), not the number based on working hours, so they differ from the HII data. However, the trends are similar.
29 Health Expenditure and Sources of Funding (SORS), 23 October 2008. Health expenditure data are collected according to the internationally comparable system of health accounts (the SHA methodology being introduced by Eurostat, OECD and WHO members).
The growth in total health expenditure as a share of GDP is slower than in most EU countries.
Figure 18: Total (public and private) health expenditure as a share of GDP, in USD PPP per capita, EU-27, 2006, in %
0 1000 2000 3000 4000 5000 6000 7000
0 2 4 6 8 10 12 14
France Germany Belgium Portugal Austria Denmark Sweden EU–15 Greece Italy Spain U. Kingdom Hungary Slovenia Finland EU–27 Ireland Bulgaria Slovakia Luxembo… Latvia Czech R. Lithuania Poland Cyprus Estonia Romania In USD PPP
As a % of GDP
Private expenditure (left axis) Public expenditure (left axis)
Total health expenditure per capita (right axis)
Source: OECD Health Data 2008 for all countries except Bulgaria, Cyprus, Estonia, Latvia, Lithuania, Malta and Romania; data for these countries are from WHO The World Health Report, 2008; data for Slovenia from SORS, Health Care Expenditure (First release, 23 October 2008); 27 and EU-15 average for private and public expenditure calculated by IMAD.
Note: Data for Bulgaria, Cyprus, Estonia, Latvia, Lithuania, Malta and Romania are for 2005 and per-capita expenditure in USD PPP for 2004;
EU-27 and EU-15 averages in USD PPP are for 2004.
30 The compensation of employees was increasing by an average of only 0.9% a year in real terms in the period 2001–2006 and gross fixed capital formation by 3.1% (General Government Expenditure by Function (SORS), 28 December 2007).
31 According to the System of Health Accounts methodology, private expenditure also includes corporate expenditure, which accounted for 10.5% of total private expenditure in Slovenia in 2006 (0.2% of GDP), and expenditure of non-profit organisations, which at 0.04% of total private expenditure is probably still underestimated.
period, public health expenditure rose by an average of 3.3% a year and private expenditure by 4.0% a year in real terms. In most other countries for which data are available (OECD members), the average real annual
growth of public health care expenditure outpaced GDP growth in this period. In Slovenia, the moderate growth of public expenditure on health is partially attributed to the streamlining of certain health care programmes and measures to reign in expenditure on drugs, but it is mostly a result of very low salary increases in the sector and slow growth of investment.30 Yet, these trends are coupled with staffing problems, worn-out medical equipment and delays in the introduction of the latest medical technology and new medicines.
Private health expenditure accounted for 27.7% of total expenditure in 2007, which is marginally less than in 2005 (28.0%)
and approximately on a par with the EU-27 average (27.4%). Nine EU-27 countries had a
higher share of private health expenditure than Slovenia in 2006, with the highest shares recorded in Greece, Cyprus, Latvia and Bulgaria. Voluntary health insurance accounts for 47.0% of private health expenditure31 in Slovenia. Direct household out-of-pocket expenditure is
Figure 19: Average real annual growth in public expenditure on health as a share of GDP, selected countries, 2001–2006, in %
DE AT SI PT
DK
IT BE
NO CA SE FR
CZ GR PL FI ES
US UK
LU IE
0 2 4 6 8 10
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5
Real annual growth of public health expenditure, in %
Real annual growth of GDP, in %
Source: OECD Health Data 2008; for Slovenia: SORS, Health Care Expenditure (First release, 23 October 2008).
Note: Data for Belgium is for the period 2000–2005.
With public expenditure on health care increasing only incrementally, the share of private expenditure is rising.
Figure 20: Private expenditure as share of total health expenditure, EU-27, 2006, in %
0 10 20 30 40 50 60
Greece Cyprus Latvia Bulgaria Netherlands Romania Poland Hungary Spain Portugal Slovenia EU-27 Belgium Slovakia Lithuania Austria Estonia Malta Italy Germany Finland Ireland France Denmark Sweden U. Kingdom Czech R. Luxembourg
Share, in %
Source: OECD Health Data 2008 for all countries except Bulgaria, Cyprus, Estonia, Latvia, Malta and Romania; data for these countries from WHO, 2008; data for Slovenia from SORS, Health Care Expenditure (First release, 23 October 2008); EU-27 and EU-15 averages calculated by IMAD.
Note: Data for the EU-27, Bulgaria, Cyprus, Estonia, Latvia, Lithuania, Malta, Romania and Luxembourg are for 2005.
low compared to EU countries as it accounted for 42.5%
of private expenditure (nearly 80% in the EU-27), but it has been rising faster than spending on voluntary health insurance.