Public debate on Health Services Act proposal ends

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The proposal of the new Health Services Act was finalised and presented for a public debate that took place between 10 June and 10 September 2009. The debate showed that several solutions were not well thought through and provided for a wide range of critical comments. The latter ranged from total refusal by the Medical Chamber to moderate approval within a part of the governing coalition. Comments, corrections and amendments will now be incorporated into a revised proposal for the next phase.

Recent developments

The Health Services Act (HSA), which since 1992 defines the structure of the health care system in Slovenia, regulates delivery of health services and defines the relationships between the key players, does not meet the expectations of policymakers nor those of the key partners in the health system. Therefore, the MoH - at that time part of a centre-right coalition - planned in 2008 to introduce several important changes (see HPM 13/2009 "New health reform start"), among them: 

 

• Clearly define all procedures pertinent to the process of granting concessions to private providers of health care services
• Seriously consider opening more competition among providers by liberalising the process of granting concessions
• Liberalising the market of supplementary health insurance, reducing the role of the state
• Potentially exploring the possibility of deregulating the monopoly position of the Health Insurance Institute of Slovenia as the sole insurer of compulsory health insurance in Slovenia

A new centre-left government took office in November 2008, with the general aim of bringing in more governance and state control. Most of the changes to the HSA that had been planned by the former coalition were included in the new coalition agreement, which provided for their firm setting in the proposal. Still, several issues were modified or removed, the most important being:

1. A planned abolishment of a compulsory membership in the professional associations ('Chambers') was replaced by a continued requirement for a compulsory membership for all regulated health professions (following the EU Directive on regulated health professions).
2. That public health providers are allowed to perform outpatient visits directly paid for by the patient has long been criticised. Still, these procedures are to remain part of the system. The argument is that this way these institutions could compete for purely private patients, including foreigners.
3. Institute for quality and safety (inspired by the German IQWIG) would include also the area of HTA, which remains poorly, or at least unclearly, described and defined. The role of the MoH seems more of a moderator with the key institutional arrangement remaining open.
4. The area of specialty training is supposed to be planned and quantitatively defined within the MoH with cooperation of the Medical Chamber.

 

The proposal of the new Health Services Act was finalised and presented for a public debate that took place between 10 June and 10 September 2009. The debate showed that several solutions were not well thought through and provided for a wide range of critical comments. The latter ranged from total refusal by the Medical Chamber to moderate approval within a part of the governing coalition. Comments, corrections and amendments will now be incorporated into a revised proposal for the next phase.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Basically, there are the following points that require attention:

1. Reduced influence of the professional associations - there has been a lot of controversy over their role and over the problems caused by their insistence on restricting available posts in some specialties (the medical chamber). This was to be reduced by introducing a non-mandatory membership.
2. Introducing a central institution for quality control and safety - a clearly German-inspired model was met with approval in its approach but there was less enthusiasm about its positioning within the MoH structure.
3. Remodeling hospitals by abolishing the former principles of general hospitals as the minimum setting for any hospital in order to reduce pressures on small hospitals to have obstetric and pediatric departments as compulsory structures.
4. Introduction of nursing departments in all general hospitals in order to alleviate the burden of chronic, palliative and temporary care for seriously ill patients.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers

• Political Parties

Stakeholder positions

Originally, there was uncertainty about several key solutions to be proposed by the new act, as the proposal was not based on an explicit strategy or position paper, but rather on a mixture of different ideas and changes of the present solutions. This poses a particular problem in view of discussing the principles upon which the HSA is supposed to be based.

1. The centre-left Government in office since November 2008, i.e. the MoH stepped back on some of the issues that seemed key to the priorities of the present coalition - membership in professional associations, a two-tier delivery system within the public sector (co-existence of same services being reimbursed both publicly as well as out-of-pocket), changes to the specialty training system of medical doctors, reform of the public health institutions, reduction of the share of private expenditures, reforming leadership at the primary care level with a bigger role given to primary healthcare centres as co-ordinators of care and health service delivery.
2. The opposition is opposed to some of the basic principles - less private expenditure, a lesser influence of the private sector and of professional associations, etc. One of the issues they are critical of is the fact that the HSA is discussed in isolation (the related act, regulating health care and health insurance is going to be presented later). This poses the problem that the infrastructure is discussed separately from the sources of finance.
3. Professional associations - Chambers - were strongly opposed to the proposal of introducing the possibility of several competing chambers and that of a non-mandatory membership. Both proposals were flatly rejected by all three representative associations (medical, pharmacists and nursing). The Medical chamber also disagreed with a more state-led process of determining posts for specialty training and for establishing a state-run institute for quality.

Actors and positions

Government
Health professional associations	very supportive		strongly opposed
Health Insurance Institute of Slovenia	very supportive		strongly opposed
Providers
Association of Public Providers of Health Care	very supportive		strongly opposed
Medical Chamber of Slovenia	very supportive		strongly opposed
Pharmacists' Chamber of Slovenia	very supportive		strongly opposed
Nursing Chamber of Slovenia	very supportive		strongly opposed
Political Parties
Coalition	very supportive		strongly opposed
Opposition	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

It is now to be seen how many more changes will be introduced to the proposal of the Health Services Act, which will also reflect the government's position regarding some of the most important issues. This is especially true of proposals related to reforming the role and position of the professional associations for regulated professions, the role of the private sector and the processes of co-ordination of care at all levels at an institutional base (e.g. the role of co-ordinating primary care by primary healthcare centres) and the proposed reform of hospital composition (keeping only the internal medicine and surgical departments and introducing nursing care departments to all general hospitals).

Some of the remarks have already been incorporated into the first revision of the proposal. It now remains to be seen how some of the revised solutions will be seen by other coalition partners - initial reactions show that there may be quite some disapproval. Once the proposal is agreed within the coalition it will be formally adopted by the government and sent to the parliament for a normal procedure of discussion and adoption.

Actors and influence

Government
Health professional associations	very strong		none
Health Insurance Institute of Slovenia	very strong		none
Providers
Association of Public Providers of Health Care	very strong		none
Medical Chamber of Slovenia	very strong		none
Pharmacists' Chamber of Slovenia	very strong		none
Nursing Chamber of Slovenia	very strong		none
Political Parties
Coalition	very strong		none
Opposition	very strong		none
current    previous

Positions and Influences at a glance

Expected outcome

At present, it seems that the HSA will be a rather controversial issue. If it gets modified to any greater extent, little will remain of the original ideas of the present coalition in bringing in more governance and state control. Professional associations remain firm in rejecting the proposal as such and it seems they may team up with the opposition in order to try to prevent the proposal's adoption.

There were two principal errors in the preparation of this act. First, there was no previous strategy or setting of the goals of this policy and second, as a consequence there is little more than a political intention to change and little clear evidence. The main driver for most of the key proposed changes seems to be political preference, which greatly polarises the debate and gives insufficient evidence for the changes.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

References

Sources of Information

1. Proposal of the Health Services Act for the public debate - published on the website of the Slovenian MoH on 10 June 2009.
2. Minutes of the discussion on the proposed act at the session of the Health Council, 24 September 2009.

Reform formerly reported in

New health reform start Process Stages: Legislation

Author/s and/or contributors to this survey

Tit Albreht

Suggested citation for this online article

Albreht, Tit. "Public debate on Health Services Act proposal ends". Health Policy Monitor, October 2009. Available at http://hpm.org/survey/si/a14/4