Pregledni članek / Review Pravne osnove razvoja zdravstvenega sistema na slovenskem - od razsvetljenske dobe do II. svetovne vojne Legal basis for the development of the Slovenian health system - from the enlightenment to the second world war Avtor / Author Gregor Pivec Ustanova / Institute 1Univerzitetni klinični center Maribor, Maribor, Slovenija; 2Univerza v Mariboru, Medicinska fakulteta Maribor, Maribor, Slovenija; 1University Medical Centre, Maribor, Slovenia; 2University of Maribor, Faculty of Medicine, Maribor, Slovenia; Izvleček Abstract Ključne besede: Odnos bolnik – zdravnik je bil sko- Throughout the history of medicine, odnos bolnik – zdravnik, zi vso zgodovino medicine intimne patient-doctor relationships remained zdravstvena dejavnost, zdravstvena narave. Temeljil je na pričakovanjih intimate and were based on the pa- zakonodaja, razvoj zdravstvenega sistema, zdravstvena politika bolnika, ki so bila več ali manj ome- tient’s expectations, which were more jena s strokovnim znanjem zdravni- or less limited by the expert knowledge Key words: ka. Ekonomsko razmerje med njima of the physician. At first, the economic patient-doctor relationship, je v začetku temeljilo na dogovoru, relationship between patient and doc- healthcare services, healthcare šele kasneje se je v ta odnos priče- tor was based on a personal agreement; legislation, development of the healthcare system, healthcare la vključevati tudi država s svojo state regulations were only involved policy. regulativo. V rimski dobi je bilo to later. In Roman times the relationship posredno, predvsem s higiensko za- was affected indirectly by the state, konodajo, deloma tudi različnimi mostly by the adoption of the Act on socialno – ekonomskimi predpisi. V Hygiene and partly by various social- Članek prispel / Received zgodnjem srednjem veku je karitativ- economic regulations. However, in 28.09.2015 na dejavnost samostanske medicine the early Middle Ages, the charitable Članek sprejet / Accepted z na žalost omejenim medicinskim activities undertaken by the monastic 09.11.2015 znanjem, predstavljala korak nazaj v population, with their limited medical razvoju zdravstvenega sistema. Šele z knowledge, proved to be a backward Naslov za dopisovanje / razvojem medicinskega znanja na na- step in the development of the health- Correspondence stajajočih univerzah, predvsem v času care system. It was not until the de- prim. doc. dr. Gregor Pivec, dr. med. renesanse, so predpisi znova posegali velopment of medical knowledge at the Univerzitetni klinični center Maribor, na področje zdravstvene dejavnosti, emerging universities, especially during Ljubljanska ulica 5, boljše izobraževanje zdravnikov pa je the Renaissance, that regulations re- 2000 Maribor, Slovenija postalo znanilec novih časov. V razi- entered healthcare and the better edu- Telefon +386 23212500 skovanem obdobju (od razsvetljenske cation of physicians marked the new E–pošta: [email protected] dobe do II. svetovne vojne) se je drža- era. During the investigated period ACTA MEDICO–BIOTECHNICA 13 2015; 8 (2): 13–22 Pregledni članek / Review va dokončno oblikovala kot tretji deležnik v sistemu, saj (from the Enlightenment to the Second World War), the se je poleg zdravstvene dejavnosti oblikovalo zdravstveno state, as a third party, was completely integrated in the sys- zavarovalništvo, kar je bil začetek zdravstvenega sistema. tem. Furthermore, in addition to the existing health services, To je predstavljalo kvalitetno osnovo za razvoj sodobne health insurance was established, which marked the begin- medicine in ureditev tako imenovane socialne države. V ning of a healthcare system. This formed a solid foundation članku je na pregleden način obdelana osnovna zdravstve- for the development of modern medicine and the regulation na zakonodaja na slovenskem v štirih različnih razvojnih of the so-called welfare state. This article discusses the ba- obdobjih, in sicer Habsburške monarhije, Avstroogrske, sic healthcare legislation in Slovenia during four different Kraljevine SHS (Srbov, Hrvatov in Slovencev) in Kralje- development periods; the Habsburg Monarchy, the Austro- vine Jugoslavije. Prikazan je razvoj zdravstvenega sistema Hungarian Monarchy, the State of Slovenes, Croats and v tem občutljivem obdobju, tako da je posebej s pravnega Serbs, and the Kingdom of Yugoslavia. The development vidika obdelano zdravstveno zavarovalništvo in na drugi of the healthcare system during this sensitive era is clearly strani zdravstvena dejavnost. Vse to je pripeljalo do obli- described; the changes in healthcare services are presented kovanja socialno-zdravstvene politike, brez katere sodobna and healthcare insurance is analysed from a legal point of država ne more obstajati. view. All of this led to the formation of the social healthcare policy, which signifies the existence of a modern state. Na razvoj zdravstvenega sistema v Sloveniji sta vplivala dva pomembna dejavnika. Prve so bile reforme, ki sta jih The development of the health system in Slovenia was main- uvajala cesarica Marija Terezija in njen sin Jožef II. konec ly influenced by two significant factors: firstly, by the reforms 18. stoletja. Drugi pomemben dejavnik je bilo ustanavlja- initiated by Empress Maria Theresa and her son Joseph II nje zavarovanja približno sto let kasneje. at the end of the 18th century and, secondly, by the establish- ment of insurance some one hundred years later. GENERALE NORMATIVUM IN RE SANITATIS AND THE PEST REGLEMENT Maria Theresa reigned from 1740 to 1780 and was the empress's adviser in this field. As a knowledge- very adept at selecting her advisers. One of her main able physician, he implemented numerous reforms, advisers in the field of economics was Joseph von Son- of which the General Norm of Health Services and the nenfels, a representative of mercantile and public fi- Pest Control Regulations were the most important. Both nance economic theories, who advocated population were implemented in 1770 (1, 2). growth as one of the most important factors for eco- nomic strength and national development. Indirectly, Gerard van Swieten was introduced to the Emperor’s he promoted higher birth rates and reduced mortality family in Holland, where Maria Ana—the sister of Ma- rates. The mortality of newborns and small children ria Theresa—gave birth in 1740. Since he was a pupil was particularly distressing and was reflected in short of Herman Boerhaave, he was sent to Brussels to help life spans. her deliver the baby, which he did so successfully. A year after that Empress Maria Theresa appointed him The population's state of health needed to be im- as her adviser (3). proved in order to achieve a longer life expectancy. Hence, health reforms were essential. Gerard van Healthcare was improved by introducing the General Swieten, born in Leiden, Holland (1700–1772) was Norm of Health Services, which included the mandato- 14 ACTA MEDICO–BIOTECHNICA 2015; 8 (2): 13–22 Pregledni članek / Review ry training of physicians, wound surgeons, surgeons, facilitated the introduction of the reforms that were pharmacists and midwives for the entire monarchy. variously enacted in different European countries at In addition, van Swieten implemented controls over that time. In France, the bourgeois revolution made the work of physicians and defined every main task of a major contribution with its principles of equality. the health protection services (4). In England, education was based on bedside prac- tice; however, the research tradition in universities The second Act on the Plague included provisions on since the time of William Harvey was also not ne- plague prevention based on Adam Chenot’s (1721– glected. In the German-speaking countries, particu- 1789) experience. In Transylvania, he realised that lar Austria, reforms were enacted in a compulsory fleas, as well as rats, carry the risk of disease transmis- manner. sion (5). Van Swieten ensured that the faculties retained their However, some epidemiological measures were al- right to issue permits to practice medicine (venia prac- ready practiced prior to these findings. For passen- ticandi); however, the dean was subordinated to the gers travelling from the East, a sanitary cordon was study director, who was a state official. His duty was implemented in 1731 at the Military Frontier. Similar to exercise control over examinations and lectures. quarantine-like measures were adopted in harbours, Hence, the role of the dean was clearly subordinated like Venice. The Contumaz und respective Reinigungs and in the period between 1780 and 1791 the dean Ordnung (1731), and particularly the Pest Reglement, of the medical faculty in Vienna was not elected. Van 40 years later, enacted protective measures regarding Swieten himself assumed the position of study direc- the spread of infectious diseases (6). tor. In this way, medical study in Vienna and Prague, as well as in other crown lands, was reformed. The The Military Frontier was located on the border with diploma of the medical faculty was valid throughout the Ottoman Empire and ranged almost 2,000 kilome- the monarchy. However, those who received their per- tres from Senj on the Adriatic Coast to the Carpath- mits at other Austrian faculties or universities could ian Mountains. It was created in the 16th Century practice medicine only in certain regions, mostly in to act against incursions from the Ottoman Empire. their own province. In addition, van Swieten carefully In some parts it was guarded by fortifications or bor- selected examiners