Regional Study Tour 2019

PRIMARY HEALTH CARE 28th January – 1st February 2019

FINAL REPORT

TETRAS d. o. o. Dorjan Marušič Contents

1 Background ...... 3 1 Objectives of the Study Tour ...... 4 2 Program ...... 5 3 – background ...... 7 4 Activities ...... 12 4.1 Introduction...... 12 4.2 Meeting at Ministry of Heath ...... 13 4.3 Meeting at Health insurance Found...... 19 4.4 Meeting at Primary Health Care Centre Sevnica ...... 20 4.5 Meeting at Primary Health Care Centre ...... 22 4.6 Wrap up ...... 25 5 Actors ...... 27 6 Conclusions ...... 28 7 Annex - list of presentations ...... 29 7.1 PPT for introduction ...... 29 7.2 PPT form HIF ...... 37 7.3 PPT from PHC Sevnica ...... 42 7.4 PPT from PHC Ljubljana ...... 48 7.5 PPT at wrap up ...... 53

1 Background

The Swiss Development and Cooperation (SDC) invests in Albania, Bosnia and Herzegovina and Kosovo in the health sector – in the frame of its respective Swiss Cooperation Strategies. Most of the Swiss health interventions are supporting the primary health care level of the public health system. Community mental Health care, nursing, integrated care; multi-sectoral health promotion and prevention are other important aspects of the Swiss portfolio in the Balkans.

The regional health advisor has in its function to organize and foster regional exchange and learning among the three programs. This year a study tour shall allow getting insight into a similar but advanced system through a study tour in Slovenia and exchange on the selected topics among the participants. Some basic reflections for a strategic paper on the future orientation of the Swiss health engagement could be another result of this exchange.

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1 Objectives of the Study Tour

The objective of the Study Tour is to learn from a country in the region that is a member state in the European Union- how it tackles the most pressing public health issues of its population. The participants shall get an understanding of the following aspects:

1. The Public Health System in Slovenia (roles and responsibilities of the different actors, Structure and Financing, decentralization level, regulation) including Public and Private sector

2. The Health care services at Primary Health Care level with the following aspects: Role of nurses and doctors, management structures, quality assurance, Health Information System/Data, home based care models and dealing with demographic change

3. The organization and functioning of the integrated care model in remote and urban areas

4. Health Promotion and Prevention – system in place, financing, results

Members of the delegation:

• Maja Zarić

• Merita Mustafa

• Bernhard Soland

• Liliane Tarnutzer

• Zhenihen Zanaj and

• Debora Kern.

Organizers:

• Dorjan Marušič, expert, Tetras

• Martina Marušič, koordinatorka ? Tetras

• Marša Marušič, oblikovalka ?, Tetars

Tu dajta blj fancy vsebine dela

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2 Program

MONDAY, 28.1.2019 as planed Arrival GRAND HOTEL UNION BUSINESS, Miklošičeva cesta 3

19.00 Dinner with briefing RESTAURANT ŠESTICA, Slovenska cesta 40 Presentor: DORJAN MARUŠIČ

TUESDAY, 29.1.2019

9.00–10.45 INTRODUCTION to Slovenian Health System, Demogra- GRAND HOTEL UNION BUSINESS, meeting room phy and Burden of Disease Presentor: DORJAN MARUŠIČ

11.00–13.00 MEETINGS AT THE MINISTRY OF HEALTH – MINISTRY OF HEALTH, Štefanova ulica 5 The Public Health System in Slovenia (roles and responsibilities of MoH, Structure and Financing, decentralization level, regulation) including Public and Private sector Presentors: TANJA MATE, director Directorat for health care MOJCA ČINČ GODEC, director Directorat for public care

13.00–14.00 Lunch DETERMINED ON SITE

14.00–15.30 MEETINGS WITH HEALTH INSURANCE FUND – HEALTH INSURANCE FOND (ZZZS), Miklošičeva cesta 24 The Public Health System in Slovenia (roles and responsibilities of HIF, Structure and Financing, decentralization level, regulation) Presentor: BORIS KRAMBERGER

19.00 Dinner TO BE DETERMINED

WEDNESDAY, 30.1.2019

8.30 Departure from hotel GRAND HOTEL UNION BUSINESS

10.00–12.30 MEETING AT PHC SEVNICA – PRIMARY HEALTH CARE CENTER SEVNICA Role of nurses and doctors, management structures, quali- ty assurance, Health Information System/Data, home based care models and dealing with demographic change. Presentor: VLADIMIRA TOMŠIČ

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12.30–13.00 Coffee break SEVNICA

13.00–15.00 MEETING AT PHC SEVNICA – PRIMARY HEALTH CARE CENTER SEVNICA The organization and functioning of the integrated care model in remote and urban areas Presentor: VLADIMIRA TOMŠIČ

15.00–18.00 Social event SEVNICA

THURSDAY, 31.1.2019

9.00 MEETING AT PHC LJUBLJANA – PHC LJUBLJANA, ulica 9 The organization and functioning of the integrated care model in urban areas AND Role of nurses and doctors, management structures, quality assurance, Health Infor- mation System/Data, home based care models and deal- ing with demographic change. Presentor: RUDI DOLŠAK

11.00 Wrap up GRAND HOTEL UNION BUSI- NESS, Presentor: DORJAN MARUŠIČ meeting room

13.00 Lunch DETERMINED ON SITE

16.00–18.00 INTERNAL SDC WORKSHOP on input paper Health in the GRAND HOTEL UNION BUSI- NESS, WB All SDC staff Meeting room

19.00 Dinner with all presenters DETERMINED ON SITE

FRIDAY, 1.2.2019 as planed Departure GRAND HOTEL UNION BUSI- NESS

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3 Slovenia – background

Number of inhabitants (2016): 2.1 million

GDP p.c. (2016): 24 100 EUR PPP

Life expectancy and health level 2016: 81.3 years (M: 78.2, F: 84.3). Health life years expectancy at birth: F: 57.9.2 and M: 58.7 years. 67% of Slovenians report to be in good health.

Causes of mortality: Although mortality rates from both cancer and cardiovascular diseases have fallen since 2000, they remain above the EU average, and for men they are actually among the worst in Europe. External causes represent the third largest group of deaths for men and rank fifth for women, mainly because of the high numbers of falls, mostly in old age, in both groups and suicides. In 2014, Slovenia ranked fourth in terms of mortality from suicide in the EU, with particularly high levels among men and large regional disparities between western and eastern Slovenia.

Risk factors: In 2014, 19% of adults in Slovenia smoked tobacco every day, which is slightly below the EU average and down from 24% in 2001. Obesity rates, however, are above the EU average and for adults have increased from 16% in 2007 to 19% in 2014. What is more, 20% of 15-yearolds were either overweight or obese in 2014, the fifth highest level in the EU, with boys particularly affected. This is despite reporting above average levels of physical activity. An important contributor seems to be the deteriorating diet of Slovenian adolescents in recent years. Slovenians appear to have some of the worst dietary behaviour in the EU with less than one in three eating fruit and vegetables regularly, more than one in three consuming sugar-sweetened beverages regularly and every second child skipping breakfast. Slovenians also have the second highest level of salt intake in the EU, an important contributor to the fact that a quarter of the population had high blood pressure in 2014. Repeated drunkenness among 15- year-olds is higher than in most EU countries, but binge drinking among adults is close to EU average. The alcohol consumption among adults is 11.5 litres in 2015.

Total health expenditures (THE): In 2015, Slovenia spent EUR 2 039 per head on health care, compared to the EU average of EUR 2 797. This equals 8.5% of GDP, which is also below the EU average of 9.9%. However, its health system is one of the most expensive among the newer Member States. Only 71.1% of health spending is publicly funded compared to 78.7% at EU level. However, only 13% of private health expenditure is paid out of pocket as the role of voluntary health insurance is significant, at 14%. There are immense issue with the role of voluntary health insurance, it being mostly complementary.

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The key challenge is to diversify the resource base with more reliable funding and to reduce the pro- cyclicality of health care expenditure.

Human resources: Despite a steady increase in physicians, partly driven by migration from neighbouring countries, Slovenia has one of the lowest physician densities in the EU. In 2014, the number of general practitioners and paediatricians still lagged behind most EU countries, leading to problems of access and over-referrals to specialist care in some parts of the country. Nurse density was slightly above the EU average. The shortage of medical doctors is well recognised but persists even though a second medical faculty was opened in Maribor (in 2003) and provision has been made for more foreign doctors to practice in Slovenia. Given the difficulties in addressing shortages and that specialists outnumber family medicine doctors (despite the importance of primary care) there may be a need for task substitution. A suggestion would be enhancing the scope of practice for community nurses to optimise patient-centred care.

Hospital sector: Outpatient (or ambulatory) specialist services in hospitals and outpatient clinics are paid on a fee-for-service basis, whereas inpatient care is covered (in theory) by fixed allocations and Diagnosis-Related Groups (DRG). However, in practice, hospitals are allocated budgets according to available resources and historical volumes and they usually continue to treat patients after having reached the nominal DRG-based budget cap. Slovenia operates a typical gate-keeping system, in which patients need a referral for an outpatient (or ambulatory) specialist or hospital consultation. Although the primary care system is strong, particularly since 2011 when the government upgraded family medicine practices and increased the emphasis on prevention and care coordination, service organisation and delivery overall are highly fragmented. The availability of health care services is generally good. However, waiting lists represent a challenge, although they seem not to have translated into an elevated unmet need due to waiting. The share of people reporting waiting times increased from 6% in 2007 to 13% in 2015, for outpatient (or ambulatory) specialist services. This is probably the effect of fiscal consolidation measures during the crisis, lack of doctors and over-referring by primary care physicians. The number of acute hospital beds and the average length of stay have decreased since the early 2000s. This reflects several factors: the shift from bed-day payments to case-based (DRG) payments; tariff reductions and rationalisation during the crisis; and the rise of day care (from 11.1% of all hospital cases in 2005 to 30% in 2013). As a result, the number of beds is now around the EU average while the average length of stay is well below average 6.8 days compared to 8 days (2015). However, bed occupancy rates are well below the EU average, suggesting overcapacity. This, together with the

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fact that there are still many smaller regional hospitals, suggests that there is room to rationalise the hospital network to improve efficiency; notwithstanding the public opposition this is likely to prompt.

Preventive health care: The effectiveness of cancer prevention and treatment in Slovenia has improved markedly. Survival rate of women with breast cancer has reached 83.5% for the period 2010–14 and is now in the top third of EU countries. Colorectal cancer survival rates have also risen and are now better than many other countries with available data. Yet even with a comprehensive screening programme in place, good outcomes are not guaranteed as exemplified by the cervical cancer programme showing a modest decrease in 5-year survival rates. Measures are in place to limit the harmful use of alcohol, including a ban on selling alcohol to those under the age of 18, as well as a high excise duty on beer (one of the highest in the EU) and pure alcohol. However, there is no excise duty on wine (the most commonly consumed alcohol) and the allowed quantities of homemade alcohol were raised in 2016. Overall, there is room to further consider excise taxes and incentives. Legislation restricting smoking in closed public spaces came into force in 2007. Since then, lung cancer mortality has decreased – although this probably partly reflects a decline in smoking prevalence that started even before these prevention measures. The 2014 reform on family medicine practices may also have long-term benefits as it strengthened prevention activities, with designated nurses responsible for screening, counselling and follow up of patients involved in smoking cessation programmes. Most importantly, new legislation on tobacco control adopted in February 2017 has introduced strong health warnings on packaging (also, from 2020, plain packaging will be mandatory), a total ban on advertising and the promotion of all tobacco products, and a ban on smoking in all vehicles in the presence of minors. The same restrictions apply to e-cigarettes, herbal smoking products and novel tobacco merchandise.

Decision making powers: Slovenia operates a compulsory Social Health Insurance system with a single payer, the independent Health Insurance Institute of Slovenia (HIIS). It provides near universal coverage. Governance and regulation are centralised within the Ministry of Health, which also owns all public hospitals and national institutes. Communities are responsible for the organisation of primary care, including capital investment in primary health centres and pharmacies.

Information technology: Slovenia has made substantial efforts to strengthen its health information infrastructure through its national e-health project. The e-prescription system is widely used by all providers and has improved interoperability and transparency. The e-registry of patient data and patient summaries is being implemented, as is the registry of health care providers, making for easier exchange of information between providers. Other e-health initiatives are being rolled out, such as an e-referral

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system, which is soon expected to completely replace paper referrals; the e-booking system, which started in late 2016; and the zVem patient portal (enabling patients to see their own medical data) which launched in January 2017.

Quality assurance: Although most hospitals are accredited by international accreditation organisations, implementation of other recommendations under the National Strategy for Health Quality (2010–15) has lagged plans. Systems for internal monitoring of patient safety, quality of care and uptake of evidence-based clinical guidelines were not set up in a uniform and structured manner. In 2011, a broad set of quality indicators was set out with the expectation that hospitals would monitor and publish their performance. However, data limitations and the lack of external verification have impeded the reliability of the approach. Similarly, safety indicators (patients’ falls and methicillin-resistant Staphylococcus aureus infection rates) are not reliable. Current efforts to establish an Agency for Health Quality and Safety as part of the NHP may help to overcome these challenges and improve quality assurance. There are also concerns that the wide range of specialised services offered by relatively small regional hospitals may undermine care quality, patient safety and efficiency simply because providers will tend to perform only a few procedures of a specific type per year.

Recent reforms and applicable measures

The biggest problems in Slovenia has been the political stalemate: although shortcomings of the health system as a whole have been identified over and over, neither policy to solve them is agreed yet and much depends on their final adoption by the government.

Health financing. The health sector has experienced delayed or failed reforms over the last few years. Health financing constitutes the most debated and difficult policy area, as evinced by a series of rejected proposals to abolish complementary health insurance. This difficulty in reaching consensus is a particular cause for concern because of the projected fiscal sustainability challenges that await Slovenia if there is no policy change. The latest reform proposal (which was not passed) proposed an extended contribution base for compulsory health insurance that takes direct and indirect income into account and unifies contribution rates across insured populations. Additional funding from general taxation would finance specific programmes (traineeships, medical specialisations and tertiary education). The reform envisages the abolition of the complementary VHI scheme by 2019, and its replacement with an income-dependent contribution that will be more efficient to administer.

Integrated care. The National Health Plan seeks to strengthen primary care and provide greater access to comprehensive and quality treatment through better care integration and a more adequate

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professional skill-mix across care levels. These reforms should also help Slovenia to respond to the changing needs of an ageing population. The upgrading of family medicine practices in 2011 was an important government initiative to improve care coordination and the management of chronic diseases. These ‘model practices’ include a designated nurse with (part time) responsibility for screening for chronic disease risk factors, preventive counselling and care coordination. By 2014, about half of all primary care provision was in such ‘model practices’ and a nationwide roll-out will be completed by 2017. This should help achieve NHP commitments to overcome the fragmentation of service organisation and to strengthen coordination between providers across different care levels

Since 2010, financial incentives have been in place to encourage the substitution of day or ambulatory (or outpatient) treatments for inpatient care. Cataract surgery has been a success with one of the highest percentages of ambulatory cases in the EU (2015). Tonsillectomies, in contrast, are still exclusively performed in inpatient settings. Hospital budgets owe more to historical precedent (through caps) than to effective purchasing and hospital deficits are ultimately borne by the government. There are therefore few incentives to make more efficient use of hospital resources. Improving the current DRG model to reflect actual costs would be one way to create greater financial incentives for increased efficiency. In response, a working group has been set up to undertake a nationwide cost analysis of hospitals’ activities in order to eventually replace the faulty DRG system currently used in the financing of hospital and specialist ambulatory activities.

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4 Activities 4.1 Introduction

The introduction to the program of Study tour was performed during unofficial dinner on 27th January by the expert, Dorjan Marušič. After brief insight to Slovenia health care system, all meetings with main actors has been presented. On 28th January, prim. MSc Dorjan Marušič, MD, BSc, international expert presented Slovenian demography and burden of disease, starting from financing and organisation to provision of health care services. The content of the presentation (in the Annex) was: • Slovenia ID

• Financing of health care system in Slovenia

• Organisation and provision of health care in Slovenia

• Health care needs

• Examples

• Conclusions

The presentation was interactive, the members of the delegation had a lot of questions. The main goal has been achieved, since the global presentation on main achievements in health care in Slovenia, especially in the field of prevention and primary health care.

Presenter: [email protected]

Power point presentation attached in Annex 9.1

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4.2 Meeting at Ministry of Heath

The delegation was accepted by two directors of directorates at the Ministry of Health: Tanja Mate, Director of Healthcare Directorate and Mojca Gobec, Director of Public Health Directorate. At the Ministry of Health there are four Directorates: Healthcare Directorate, Directorate for Long-term Care, Public Health Directorate and Directorate for Healthcare economics. The Healthcare Directorate aims to improve and develop the healthcare system by increasing the accessibility of healthcare services, whereby we aim to provide appropriate, safe, high-quality and accessible healthcare for all. Public Health Directorate strives to prevent diseases at the population level and thus reduce the burden of disease both on individuals and on society by protecting and enhancing mental and physical health and capabilities through organised and social activities. Directorate for Healthcare Economics deals with collective agreements, preparation of expert positions for the needs of a general agreement, planning material conditions for accessible, efficient and quality implementation of healthcare programmes.

The organization of the Slovene healthcare system, with all of the involved bodies, working on three main levels (national, regional and local) are below:

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On 29th March 2016, the National Assembly of Slovenia adopted a resolution on the national health care plan 2016–2025: together for a healthy society. This resolution fulfils Slovenia’s constitutional and legal obligations to provide access to appropriate, quality and safe public health care to all its residents. Through wider integration at the national level and measures in fiscal, economic, educational, social, environmental and other policies, it will create living conditions favourable for health and for a healthier lifestyle.

The Slovene health care system remains relatively centralized, as the responsibilities of municipalities have not been implemented fully, The Ministry of Health has the task of planning health care regarding state-owned providers and for the healthcare system (ensuring equal access and patient rights across the whole country). All administrative and regulatory functions of the system take place at the national level, the subnational levels have predominantly executive duties. Compulsory health insurance is also centrally managed and administers. The professional chambers and organizations also operate at the state level or through their regional branches. Municipalities seem to be making limited use of autonomy they gained to plan health services. Consequently, the de facto devolution in planning primary health care from the central government to local communities has not yet occurred.

Primary care falls under the jurisdiction of municipalities, which are responsible for health policy development at the local level. Municipalities are the owners of the community-level primary health care centres that occur all over the country. Primary health care centres are established and owned by one ore more municipalities, which are responsible for day-to day functioning of the centre as well as for administration and ensuring adequate funds for the maintenances of premises. All employees are salaried according to the terms of the general contract for employees in the public sector. The types of care provided in primary health care centres include emergency medical aid, GP/family medicine, health care for women, children and teenagers, community nursing, laboratory and other diagnostic facilities, preventive and curative dental care for children and adults, physiotherapy, ambulance services. Primary care practitioners in Slovenia include GPs, paediatricians and gynaecologists, as well as community nurses, midwives, dentists for adults and children, pharmacists, physical therapists, speech therapists, occupational therapists, psychologists or psychiatrists and other health professionals necessary to deliver care. GPs and nurses are the initial contact with patients for curative and preventive care, including general medical care, minor surgery and home visits when necessary. Community nurses support the recipient of nursing care through health promotion, prevention, curative and long-term care

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and palliative activities. Patients are entitled to select their own physician from among the physicians operating at the primary health care level (i.e. in primary health care centres). Gatekeeping – Slovenia operates under a typical gatekeeper system, and patients need a referral from their personal physician to be treated by a specialist.

In 2011, a system of family medicine – „Model practices“ was introduced. These practices include, in addition to the regular nurse (i.e. associate professional nurse), a further part-time (0,5 FTE) registered nurse who has received additional training and whose tasks include screening for chronic disease risk factors and preventive counselling for patients aged 30 and over, as well as the care coordination of all registered patients with a stable chronic disease (e.g. arterial hypertension, diabetes type 2, asthma, chronic obstructive pulmonary disease, osteoporosis,…). The purpose of family medicine „Model practices“ operation is to improve the quality of work with an active approach in the promotion of health, screening for the most current health problems of the adult population and systematic management and monitoring of patients with stable chronic diseases. The new way of work is a significant improvement in the field of family medicine patient treatment. It has also increased the accessibility of the whole population to high-quality and safe health care.

Health promotion centres (HPCs) were first created in 2002 in all primary health care centres across Slovenia. Their main role was to provide lifestyle interventions against key risk factors for noncommunicable diseases by combining population and individual approaches. Health promotion centres integrated previously dispersed activities in PHC centres, including community nursing. Between 2013 and 2016, using Norwegian funds a new paradigm was piloted in 3 such centres to assure integration of different services targeting vulnerable groups. The new role of HPCs was to create partnerships with key stakeholders, including social services and nongovernmental organizations (NGOs), to improve health at community level. Health promotion teams were established to prepare local strategies and actions plans, which would address the needs of different population groups and identify and reduce health inequalities. Based on this experience, upgraded preventive programmes and approaches in health promotion centres are now being implemented in 25 health care centres (action for years 2018 and 2019) with the European Social Fund financial contribution. These 25 upgraded HPCs include multidisciplinary teams of nurses, physiotherapists, psychologists, dieticians and kinesiologists. For the implementation of the upgrading preventive programs on children and adolescents the physicians (paediatricians) are included, as well as the registered nurse in patronage care for performing

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the additional preventive activities of the patronage service. Patients attend individual and group classes on lifestyle changes regarding healthy nutrition, physical activity and mental health; smoking, alcohol use, obesity and diabetes are addressed as well. Multidisciplinary teams in HPCs have a broad spectrum of competencies and skills to provide health promotion and disease prevention programmes within primary health care centres. Important element is working in the community by providing support to local initiatives and approaches. Primary health care centres, through HPCs, have an important role to play in delivering preventive services and public health programmes that focus on vulnerable groups within the community. In order to include vulnerable people in preventive programmes, Health Care Centres perform various activities, for example: • Escalated interventions for parents of children up to one year of age, for the areas of “Lactation and breastfeeding” and “Physical activities and handling” • An open day for health at the locations of social sector partners and NGOs, carried out by the Health Promotion Centre’s multidisciplinary team • Additional preventive treatments in community nursing • Self-assessment by the Health Care Centre regarding the provision of equity in health care for vulnerable groups by planning and implementing further measures • Assessment of the suitability of facilities and communication measures of each individual Health Care Centre for individuals with physical and/or sensory impairment • Ensuring the presence of an interpreter and/or intercultural mediator when conducting preventive treatments.

A total of 30 public and private hospitals provide care in Slovenia. There are 10 general hospitals, 2 university hospitals, 5 mental health hospitals and 13 specialised hospitals (3 of them are private). When the patients are referred, they freely choose their secondary care provider. Since most outpatient services and almost all inpatient services are provided within hospitals, accessibility is mainly related to the distance from a patient‘s home to regional centres. Ownership of the hospitals is clearly divided between the state, which is the SINGLE owner of all public hospitals, and private companies, which own private hospitals. Public hospitals are non-profit-making organizations. Private hospitals are profit- making organizations. They receive concession from the Ministry of Health and bid for contracts with the Health Insurance Institute of Slovenia. Tertiary care is provided by university medical centres in Ljubljana and Maribor, the Institute of Oncology, the University Clinic of Respiratory and Allergic Disease Golnik, the Psychiatric Clinic Ljubljana and the University Rehabilitation Institute.

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Key public health functions, which are carried out predominantly at the NIPH and NLHEF, are:

• Monitoring health, healthcare and welfare of the population • Handling health risks and health hazards • Infectious diseases and action in the event of health threats • Strengthening health and reducing health inequalities • Prevention and early detection of diseases • Advocacy, communication and community mobilization for health • Public Health Research There are differences in mortality due to cardiovascular diseases and other health indicators among Slovenian regions. These differences, as well as in other countries, are primarily a reflection of the differences in the socio-economic development of Slovenian regions.

The Ministry of Health has one of the crucial roles in supporting society in creating an environment for healthy choices in this area. The program has over 30 stakeholders which are active in its implementation. It comprises 215 measures.

The National program set priority areas

• Nutrition: o Ensuring healthy and safe food from local and sustainable production; o Nutrition aligned with recommendations and guidelines o Increasing healthy foods in tourism and services o Food industry: encourage and support healthy food production + transparent labelling and responsible marketing of food which enables consumers to easily recognize healthy choices o Accessibility of healthy choices for socially deprived and vulnerable groups • Physical activity

All this is only viable thru wide education and awareness programs. It is also evident we need a lot of partners, non-governmental and especially governmental, such as agriculture, education, tourism, environment, culture. The presentation was interactive, the members of the delegation had a lot of questions, the representatives of Ministry of health presented all achievements, positive results and potential improvements in future.

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Presenters: [email protected] [email protected]

Power point presentation attached in Annex 9.2

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4.3 Meeting at Health insurance Found

The meeting at Health Insurance Institute of Slovenia started with the presentation of Boris Kramberger, senior adviser to General director. The main parts of the presentation were. • Introduction • Compulsory health insurance • Voluntary health insurance • Total expenditure for health care in Slovenia • Conclusions

The presentation was interactive, the presenter reacted to all questions of members of the delegation., He pointed out the main achievements of HIIF, especially those related to prevention, health promotion and primary health care. He concluded with the needed further modernisation and reform of health care and health insurance system since there are demographic and socioeconomic changes, constant technology and organisation changes, new drugs, demanding clients, enormous pressures on costs and challenges related to EU and economic cycles. Presenter: [email protected]

Power point presentation attached in Annex 9.3

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4.4 Meeting at Primary Health Care Centre Sevnica

The meeting at Primary Health Care Centre Sevnica (PHCCS) was managed by general director of PHCCS Vladimira Tomšič. All members of the team were involved in the presentation of main achievements in implementing the Model practice, Health promotion centres and Community based psychiatry.

General director started with the presentation on main demographic, geographic data on municipality of Sevnica and posed the main challenge for primary health care provision in PHCCS: how to provide the same health care on similar surface area as in capital city Ljubljana but with 16 times less inhabitants (Sevnica surface area 272,2 km2 with population of 17.502; Ljubljana surface area : 275 km2 with population: 287.218) and distance pf 33 km to the local hospital, 40 km to regional hospital Celje and 90 km to University hospital Ljubljana. At PHC they do cover also health care at three elderly/nursing homes in the municipality. Some impressive results in treatment of acute myocardial infarction and bronchial asthma were PHCCS is below the national index. On the other hand, treatment of stroke and detection of new cancers is below the national average, which might be the main cause of higher cancer and cardio-vascular mortality in Sevnica compare to national average. Consumption of alcohol is one of the concerns.

There are 109 employees, 16 doctors and dentists, 6 doctors on training), 52 nurses, 21 health care co- workers, 11 non-health care co-workers and 3 managers. The PHCCS carries out basic health care at the primary level in accordance with the provisions of the Health Care Act, which is defined in the founding act of and is implemented in the following organizational units (OU): General health care (family medicine, ˝reference clinics˝ for family medicine = family medicine practice reinforced with nurse with diploma, home care, physiotherapy, diagnostic laboratory, functional diagnostics, Dental care (dental care for adults, dental care for children and youth), Emergency medical assistance, Rescue service (non-emergency transport services with escort, transport of dialysis patients, medical transport), Health promotion/improvement centre and Specialist services (anticoagulant clinic, ginecology, radiology, ultrasound, pulmology, occupational and sports medicine, cardiology, dermatology, mental health clinic (speech therapist, psychologist, special pedagogue), mental health centre for adults, community psychiatric treatment). In PHCCS they do cover marketing of services and products (marketing health and other services on the market, programs for a healthy lifestyle, the implementation of a mortuary transparent service and

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marketing of administrative and technical services). There are some non-medical activities: secretariat and administration, technical maintenance of computer information systems, hygiene cleaning service with laundry and maintenance service. Extremely important is the implementation of preventive health care at the primary level since it provides quality preventive health care at the primary level in the following areas: reproductive health care, the health of infants and children up to the age of 6, health care for school children and youth up to the age of 19, health care for students, dental care for children and young people, preventive health care for adults at the primary level, healthcare for patients treated in home care and healthcare for athletes. Important is the cooperation with NGO's, clubs and associations: Koronarni klub, Posavsko in obsoteljsko društvo za boj proti raku, Društvo diabetikov Posavja, Društvo za preprečevanje osteoporoze Posavje, AA, KZA, AL-ANON, RK, Ozara). One of the new initiatives is SOPA, the national project, co-financed by ESF: Together for a responsible attitude towards alcohol consumption. It began in October 2016 and will end in December 2020. The main goal of the project in to reduce the excessive drinking of Slovene adults and thus to prevent the negative consequences of hazardous in harmful alcohol consumption for an individual, his relative and broader society.

In the second part representatives of PHCCS presented the Model practice, Health promotion centres, Laboratory, Diagnostics and Community based psychiatry. Later, in a tour around the PHCCS all departments were visited. The visit achieved the expectation since the health care services at the primary level in rural area were presented, all positive achievements of dedicated and responsible staff were pointed out. The discussion was open, friendly, connections were built up. The visit was concluded with social event, visit of the castle follow lunch. Presenter:

Vladimira Tomšič [email protected]

Power point presentation attached in Annex 9.4

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4.5 Meeting at Primary Health Care Centre Ljubljana

Rudi Dolšak, the General director of Primary Health Care Centre Ljubljana (PHCCL) started his presentation of the organization. The PHCCL is located in the area of Ljubljana Municipality, there are 6 units (Bežigrad, Center, -, Šentvid, Šiška, Vič-), Basic emergency health care and Institute for Development and Research in primary care.

There are 1562 employees, 155 family medicine specialists, 111 dentists, 180 other doctors, 295 graduate nurses, 413 nurses, 276 other health professionals and 132 non-professional health-care workers.

After presentation of the Slovenian health care system, the main part of the presentation and discussion was on financial part.

The presentation took over by Tea Stegne Ignjatovič, Medical Director of PHCCL. She presented the organisation and reform changes on the last decade at the primary health care level with the introduction of the new model in 2011 in the areas of: human resource standards (implementation of diploma graduated nurse - practice nurse), work competences and work management (redistribution of workload). The family medicine practices obtained additional team member - practice nurse, a more defined and active approach to patients and broader prevention. The concept of performance was upgraded with use of protocols for the treatment of chronic patients, extended and well-defined preventive screenings, registers of chronic patients which are continuously updated, assessing quality by means of quality indicators, exactly defined competencies and responsibilities of practice nurses and assessing satisfaction of patients and team members once a year.

In prevention practice nurses does most of the preventive care. The preventive screenings involve individuals over 30 years old. The objective is to detect individuals with high risk factors for CV disease, diabetes or an early detection of new chronic patients with hypertension, diabetes, CVD, COPD, depression, osteoporosis, hypertrophy of prostate.

Chronic patients with stable chronic disease (hypertension, diabetes, asthma, COPD) are visited by practice nurse. Practice nurse follows the protocols for chronic disease, some include also laboratory tests. Depending on protocol, practice nurse checks blood pressure, foot status by diabetic patients, does spirometry, educates about diet, promotes taking prescribed drugs. The consultations between graduate nurse and physician on regular basis.

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The protocols for 8 main diseases are a consensus between experts from primary and secondary/tertiary health services (also regarding referring to the specialists). The protocols are pre-tested in different regions (feasibility). They do define what to do/check and when, how often while deterioration (frequency) and how to react.

Altogether there are 28 quality indicators of condition, processes and outcomes. Every indicator is defined by its measures and standards. The reporting was up to the end of 2014 manually, from 2015 onwards automatically.

Next steps should be to employ practice nurses in full time (1FTE), introduce a home care nurse as a team member in all family medicine practices – for patients that cannot come to clinics and implement unique IT template for monitoring results in FMMPs on national level.

The new model introduced active approach in the management of chronic patients and preventive care in a broader and planned way for patients. For medical staff, the new model implemented a new way for comprehensive medical care and a possibility for upgrading collaboration among different care levels.

The members of the delegations intervened several times with important and relevant questions. The discussion was intensive and friendly.

The visit ended with the presentation of the Simulation centre and SIM mobility centre for training of resuscitation.

Presenters:

Rudi Dolšak [email protected]

Tea Stegne - Ignjatović [email protected]

Power point presentation attached in Annex 9.5

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4.6 Wrap up

Based on special request of the delegation the expert prepared a presentation on the incentives implemented at the primary health care form 2000 on with a special emphasis on the Reference ambulatory model.

In 1992 structural changes has been implemented with a mixed model with choice of personal doctors on primary level (institute of gatekeeper), public and private (individual and collective) providers concessionaires, capitation with age correction and reimbursement of services, standard team (1 doctor, 1,1 nurse, 0,36 administrative worker). In 2001 new incentives in payment methods were introduced to promote prevention care. Capitation was upgraded with fee for some services and a national cap (92% of budget) with needed performed preventive care (8% of budget) and monitoring referrals to compare to the national average. In 2 years, till 2003 a 19% drop in referrals was noticed. In 2010 the preparation of a so called (no)reform started, Upgrading the Health Care System with special emphasis ion Primary health care level:

• Organisational practices: Reference (RP), Teaching (TP) and Rural (RuP)

• New role of health care centre

• Reimbursement changes

• Quality and safety

• Informatization and communication

• Measures in the field of education

• Institution for development

The main goal of new practices was to

• promote

o team work

o prevention

o integrated care

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o chronic patient treatment based on protocols

o optimal use of laboratory services

• quality indicators

• facilitate the transfer of work to the primary level through the appropriate staff-content financial structure and protocols

• improve and reward quality, safety and cost-effectiveness (P4P) in treating patients

The aim of reference practices was to increase quality, safety and cost effectiveness in patient treatment and performance of certain activities in part by the certified nurse in accordance with their jurisdiction and responsibilities. In RP physicians already worked in the public health care network but are at a high level as far as their expertise is concerned regarding integrated care, chronic patient treatment per protocols, prevention, quality indicators and optimal use of laboratory services.

The expert presented the path performed with crucial parts in nominating the minister’s adviser for primary health care, leading the project board and publicly promote the idea. Nowadays, all primary health care ambulatory performs in the reference model.

Presenter:

Dorjan Marušič [email protected]

Power point presentation attached in Annex 9.6

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5 Actors

Dorjan Marušič., international expert, [email protected] Tanja Mate, Director of Healthcare Directorate, [email protected] Mojca Gobec, Director of Public Health Directorate, [email protected]. Boris Kramberger, Senior adviser, Health Insurance Institute of Slovenia, [email protected] Vladimira Tomšič, General Director of PHC Sevnica, [email protected] Rudi Dolšak, General Director of PHC Ljubljana, [email protected] Tea Stegne Ignjatovič, Medical Director of CHC Ljubljana, [email protected]

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6 Conclusions

The Study Tour in Slovenia for the representatives of The Swiss Development and Cooperation (SDC) was focused on the primary health care level of the public health system. Specific interest was for community based mental health care, nursing and integrated care. Regarding multi-sectoral health promotion and prevention, the interest was toward national approach form the Moh toward providers and other organisations.

The organization considered all request and agreed on visits in main stakeholders, starting with Ministry of Health at two main directorates, for Health Care and for Health Prevention and promotion, then at Health Insurance Found and finally with two Primary Health Care Centres, in rural area and capital city. With the introductory and final presentation of the expert, 16 hours of intensive and interactive presentations were organised.

The main objective of the Study Tour, to learn from a country in the region that is a member state in the European Union was more than achieved. The presenters pointed out how in Slovenia the most pressing public health issues of its population are tackled. The participants got a clear understanding of the Public Health System in Slovenia:

• roles and responsibilities of the main actors

• structure and financing

• decentralization level

• regulation of public and private sector.

The provision of health care services at Primary Health Care level were precisely presented with special emphasis on the role of doctors and doctors, management structures, quality assurance, health information system, data collection and home-based care models and dealing with demographic change.

The organization and functioning of the integrated care model in remote and urban areas were clearly presented in both health care centres, in Ljubljana and Sevnica. The Health Promotion and Prevention system in place with financing and results was presented at The Ministry of Health and at the Primary Health Care Centre in Sevnica as a pilot centre for main national project.

The Study tour was successful, fulfilled all objectives and achieved expectations.

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7 Annex - list of presentations

7.1 PPT for introduction

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30

31

32

33

34

35

36

7.2 PPT form HIF

37

38

39

40

41

7.3 PPT from PHC Sevnica

42

43

44

45

46

47

7.4 PPT from PHC Ljubljana

48

49

50

51

52

7.5 PPT at wrap up

53

54

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