Historical background and context

Slovenia has a social health insurance system based on a single public insurer, the Health Insurance Institute of Slovenia, which provides universal compulsory health insurance. In addition, complementary health insurance is taken out by most of the population, mainly to cover co-payments. Health services are delivered by public providers (a network of health care centres at primary level and hospitals and outpatient clinics at secondary level), as well as private providers that hold a “concession” to provide publicly funded services. Following Slovenia’s independence in 1991, the Health Care and Health Insurance Act (1992) set out the framework for the new health insurance system and the provision of services, which largely remains in place today.

Public health services in Slovenia are considered part of the health care system and are specified by legislative acts. The 1992 Health Services Act defines “public health” as operations that include monitoring and evaluation of the health of the population and of health care; identification, monitoring and surveillance of key public health problems, risk factors and health threats; public health preparedness and response to health threats; health protection measures; disease prevention; health promotion; informing the public on the population’s health status and public health research findings; training of professionals working in public health; and public health research and education. Public health activities in the areas of health, environment and food are also defined in sector-specific legislation and include laboratory services; education and training of professionals; public information and reporting; and research. Other relevant legislation that determines the scope of public health activities in Slovenia includes the 2000 Healthcare Data Base Act and the 1995 Communicable Diseases Act.

Historically, public health services have figured prominently in the country’s health care activities. Until the early 20th century, these activities more or less reflected developments in hygiene and social medicine in the Austro-Hungarian Empire that aimed to prevent and control epidemics of communicable diseases. As early as the 19th century a medical doctor, Franc Viljem Lipič, wrote a report on the problem of alcohol consumption in Slovenia, with a proposed action plan on how to reduce its burden on health and wealth (Lipič, 2005).

In 1923, when Slovenia was part of the Kingdom of Yugoslavia (1918–1945), the physician and humanist Dr Ivo Pirc created a firm foundation for public health (according to Andrija Štampar’s model), with the establishment of the Hygiene Institute in Ljubljana. The Institute had bacteriological, epidemiological, social-medical, chemical and sanitary–technical departments and laboratories (Albreht & Klazinga, 2008).

By the time of the Second World War it had initiated the development of primary health care dispensaries in over 20 community health centres in Dravska Banovina (the Slovenian part of the Kingdom of Yugoslavia) to deal with the prevention and early detection of tuberculosis, syphilis and trachoma in the Prekmurje region. The priority of the dispensaries was to proactively screen population groups at risk (mostly children and women) for disease and to educate them about hygiene measures to protect their health. In Ljubljana, several public health initiatives were started by the Hygiene Institute, including holiday camps for children, so-called “dairy kitchens”, and physical activity lessons as part of school curricula. Most health care centres that were established in Slovenia during this period had, in addition to the primary health care dispensaries mentioned above, children’s dispensaries, school clinics and counselling facilities for mothers and children. The Hygiene Institute promoted a comprehensive approach to health, including public health functions, to be followed in the new community health care centres (Zupanič Slavec, 2012).

In the period after the Second World War the Hygiene Institute experienced several transitions. In 1951, as the Central Hygiene Institute, it assumed responsibility for monitoring, protecting and promoting the health of the population. In 1974, it was transformed into the Institute for Health Protection and in 1985 into the University Institute for Health and Social Protection.

In 1992, the University Institute was transformed into the Institute of Public Health and charged with implementing large-scale disease prevention programmes and other public health activities. Epidemiological monitoring was carried out by nine regionally based institutions for social medicine and hygiene. As a result of the 1992 Health Care and Health Insurance Act, the Ministry of Health became increasingly responsible for the strategic planning of the health system and part of its remit included a stronger focus on monitoring and preventing communicable diseases. In parallel, and accompanied by increased investment in public health infrastructure, the Institute of Public Health and its nine independent regional institutes received greater responsibilities for coordinating and delivering public health services, in particular health promotion and disease prevention programmes, and overseeing a network of well-equipped public health laboratories (Albreht & Klazinga, 2008; Albreht et al., 2016).

Following several years of debate, in 2013 a major restructuring of all public health institutes and laboratories began, culminating in the establishment of two separate public health institutions at the national level, the National Institute of Public Health (NIPH) and the National Laboratory for Health, Environment and Food (NLHEF), both funded by the government. These two organizations became fully operational in 2014 and both have structures at the regional level. Public health laboratories operate as part of the NLHEF (see below). The intention of the 2013 reform was to centralize public health operations to strengthen coordination, ensure stable streams of public funding and ensure equitable access to public health services across the country. Previously, there was a lack of cooperation and coordination between the independent regional institutes, and programme priorities were often funded through market activities, such as providing laboratory services. While some of the regional public health institutes were very successful in these activities, others generated debts and required subsidies from the government budget.

Along with the recent institutional strengthening of public health functions, Slovenia has signalled the importance of public health activities through its National Health Plans. The National Health Plan 2008–2013, for example, featured a number of public health actions and measures for the development of preventive services and health promotion activities. The current National Health Plan, covering the period 2016–2025, singles out health promotion, health protection and disease prevention as one of four priority areas of health system development (Ministry of Health, 2016a). This continued focus on public health builds on some of the major milestones over the past 20 years, namely passing legislation (1999) and national programmes (2004 and 2013) on illicit drugs, adopting national strategies on prevention and control of HIV/AIDS (1995 and 2004), introducing measures to restrict alcohol consumption (2003), introducing a total smoking ban in public places (2007), establishing national programmes and plans in the areas of cancer and diabetes (2010) and adopting national plans on nutrition and physical activity (2005 and 2015) (Albreht et al., 2016).

Organizational structures

In Slovenia, key public health institutions and main operations of public health are, as mentioned above, defined by law. A number of organizations are involved in public health policy-making and the planning and provision of public health services (Figure 9-1).

Figure 9-1

Organizational structure of public health services in Slovenia. Source: Authors’ compilation

Nationally, the Ministry of Health is responsible for the overall stewardship of the health system, encompassing both health policy and health protection (Albreht et al., 2016). As part of this role it monitors public health and develops and coordinates the implementation of public health policies, such as the above-mentioned national plans or strategies on nutrition and physical activity, diabetes, cancer, illicit drugs and environmental health. The policies are implemented through yearly or biennial action plans that provide a mechanism to ensure vertical and horizontal coordination of all stakeholders in public health, including NGOs. The Ministry is also responsible for the implementation of legislation and guidelines in different public health domains, including legal and illicit drugs, safety and health promotion at work and in traffic, preventive programmes in primary health care, chemicals, cosmetic products, radiation protection, food safety, and environment and health.

The Ministry of Health has a dedicated Directorate of Public Health which has two divisions, the Division for Control of Communicable Diseases, Food and the Environment and the Division for Health Promotion and Control of Noncommunicable Diseases. The Directorate has a mandate to prevent disease and to reduce its burden on individuals and society through the protection and promotion of mental and physical health and the prevention and control of communicable and noncommunicable diseases. Its remit covers strategic oversight of all public health areas, including prevention of HIV/AIDS, tobacco control, alcohol policy, nutrition and physical activity, drug dependency prevention and harm reduction, vaccinations, food safety, environmental health and the coordination of activities in case of outbreaks. It is responsible for formulating policies in these areas and for their implementation.

The Ministry is supported in its health care and public health planning tasks by a special advisory body, the Health Council, whose remit includes considering proposals of health care and public health programmes, new technologies, and health education and research initiatives from the point of view of their feasibility, accessibility, the balanced development of all professions and their financial impact, in accordance with the needs of the population.

The Ministry’s Health Inspectorate has an important role in overseeing the implementation of national public health legislation and policies. Through its nine regional units (established in 1995) the Inspectorate supervises, inter alia, sanitation, hygiene, the implementation of tobacco and alcohol regulations, and the environmental protection of the population at the national, regional and local levels.

Other Ministry of Health bodies that play a public health role are the Chemical Office, responsible for preparing and implementing measures to protect the natural environment and health of the population against the harmful effects of chemicals, and the Radiation Protection Administration, performing tasks related to the protection of human health against the harmful effects of ionizing and non-ionizing radiation.

Since 2014, public health services have been provided by the National Institute of Public Health (NIPH), based in Ljubljana, and its nine regional offices, as well as by the National Laboratory for Health, Environment and Food (NLHEF), based in Maribor. Both the NIPH and the NLHEF are public institutions funded by the government.

The NIPH is the central public health institution in Slovenia, carrying out a wide range of public health functions, as well as research, education and postgraduate training. The NIPH has broad responsibilities, including assessing population health, health care, and health system resources and performance. In addition, as the only authorized producer of official statistics on health, the NIPH is a central reporting point on national health statistics for the National Statistical Office, as well as for international organizations, such as the World Health Organization (WHO), the European Commission and the Organisation for Economic Co-operation and Development (OECD). It maintains several databases, including the national death register, a hospital statistics database, an outpatient statistics database, a database of national health care providers and a database of health professionals. The NIPH also carries out surveys of different target populations, including large-scale surveys on lifestyles and health determinants (e.g. drug use, alcohol consumption, dietary habits and sexual health), and undertakes analyses of health determinants and their impact on health. Its other core public health functions include the surveillance of communicable diseases, vaccination programmes and the stockpiling and distribution of vaccines across the country, for which it is the sole importer and distributor. In the area of environmental health, the NIPH prepares risk assessments and evaluates environmental impacts on health (Albreht et al., 2016). Following the reorganization of public health institutes in 2013, the primary role of coordination, monitoring, assessment, management and provision of health promotion, prevention and screening programmes was consolidated and assigned to the NIPH, with the exception of the screening programmes for cervical and breast cancer that are operated by the Institute of Oncology in Ljubljana. In order to deal with its new tasks, the NIPH established a Centre for the Management of Prevention and Health Promotion Programmes, which designs, monitors and coordinates national prevention and screening programmes, including those aimed at changing lifestyles.

The NIPH is also a founding organization of the Centre for Health and Development Murska Sobota that was established in 2005 to build capacities for reducing inequalities in health, and to promote investments in health and development in the Pomurje region. The Centre is a WHO Collaborating Centre for Intersectoral Approaches to Health and Development.

The National Laboratory for Health, Environment and Food (NLHEF) was created as a separate entity during the institutional restructuring process that took place in 2013. It is now the central and only public health laboratory in Slovenia. Its functions range from microbiological testing for health care providers to the isolation of pathogens for epidemiological surveillance; it also designs and coordinates monitoring programmes at the national level. On behalf of the Health Inspectorate, the NLHEF performs sampling of water, food products, chemicals, alcohol and tobacco, as well as testing of domestic and commercial environments. In close coordination with the NIPH it also prepares assessments of environmental risks. Both the NIPH and the NLHEF are required to submit annual reports on their mandated activities to the government and publicly on their web sites.

The Institute of Occupational, Traffic and Sports Medicine at the University Medical Centre Ljubljana has responsibility for health promotion and disease prevention of occupational diseases.

The Institute of Oncology, the principal national institution for the comprehensive management of cancer in terms of prevention, early detection, diagnostics, treatment and rehabilitation, research and education, operates the national cancer registry, the hospital-based cancer registry, the cancer epidemiology unit, and the screening programme registries ZORA (for cervical cancer screening) and DORA (for breast cancer screening). The national cancer registry, set up in 1950, is one of the oldest population-based registries in Europe.

Other important stakeholders in the delivery of public health services at the local level are providers of primary health care and NGOs specialized in different areas of public health. There has been a shift in primary health care, from predominantly treatment services to more preventive services and early detection of disease, partly due to the introduction of a national screening programme on cardiovascular diseases in 2002 and of organized cervical cancer screening in 2003, as well as the establishment of Health Education Centres within primary health care centres (Zakotnik, Fras & Zaletel Kragelj, 2007). At the same time, a financial incentive was introduced for those primary health care providers (public and private) implementing preventive check-ups. Since 2011 a new family medicine framework, called “model practices”, has implemented prevention and monitoring activities for the most prevalent chronic noncommunicable diseases (Poplas-Sušič & Marušič, 2011). The paradigm of model practices is being rolled out to include all family practices by 2018; it involves having an additional 0.5 full-time equivalent registered nurse to carry out activities such as screening for chronic disease risk factors, preventive counselling of patients over 30 years and care coordination of registered patients with stable chronic diseases. In 2013–2016, a new model of Health Promotion Centres (an upgrade of Health Education Centres) has been piloted in three primary health care centres (in Vrhnika, Sevnica and Celje). This model will be implemented in an additional 25 primary health care centres by 2020, according to the 2016 National Health Plan. The aim is to better integrate preventive services in primary health care; establish partnerships for health in local communities (with, for example, social care centres and employment agencies); and reduce inequalities in health.

NGOs have been successful in building coalitions in support of tobacco control, advocating for stronger alcohol and road safety policies, and implementing drug harm reduction and HIV/AIDS prevention programmes. On the other hand, programmes implemented by NGOs are rarely externally evaluated, the workforce is often not educated in public health, and a frequent lack of continuous financing is hindering these organizations in expanding their programmes and investing in their staff. There is also an absence of professional guidelines for working with different population groups in various areas of public health.

The financing of public health services

The health system in Slovenia is mainly financed through social health insurance contributions. General taxation at national and municipal levels is another, albeit modest, public source of funding for the health system, accounting for 3.3% of current health expenditure in 2014 (Albreht et al., 2016). Both sources are used for financing public health services, including specific public health and prevention programmes, such as national screening programmes for breast, cervical and colorectal cancer.

Over the period 2003–2013 a little less than 4% of current health expenditure from public sources was spent on prevention and public health services, ranging from 3.78% in 2003 to 3.69% in 2013 (Albreht et al., 2016).

In 2015, approximately €8 million was assigned from the Ministry of Health budget for public health services, with the funds being managed by the Public Health Directorate. From this total amount, €5.9 million was allocated to the NIPH, €0.7 million to the NLHEF for monitoring the impact of the environment on health, €176 000 to co-finance EU projects, €83 000 to co-finance research and studies in public health, and €0.5 million to co-finance projects through the Ministry’s 2015–2016 public health tender process (see below). In addition, the Ministry of Health co-financed the Centre for Health and Development in Murska Sobota with €97 350, as part of cooperation programmes with WHO (for the Ljubljana Summer School) and other activities. The Cancer Registry is financed by the Health Insurance Institute.

In 2016, the Ministry of Finance rejected the proposal from the Ministry of Health to earmark tobacco tax for spending on health (with an estimated revenue from excise tax on tobacco of approximately €450 million per year), but instead agreed to increase the budget for public health activities by about €4 million in 2017, most of which is to be distributed to NGOs and not-for-profit institutions by public tender.

The public health workforce

Quality assurance and performance measurement

Quality assurance and control in public health have so far been developed only in selected institutions and programmes, partly due to the importance assigned to it by managers. At the national level quality assurance has not yet been systematically institutionalized in the health sector which has also resulted in uneven developments in the area of public health.

The establishment of an independent national body for quality assurance in the health system has been on the agenda of several governments, but so far without success. In the 2016 National Health Plan, quality assurance in the health system, including public health, is one of the key priorities. However, it will take time to identify appropriate indicators and define responsibilities for quality management. The experience with quality assurance in primary health care, such as in the management of diabetes, suggests that one of the preconditions for establishing a functioning quality assurance system is to determine the roles and responsibilities of staff and management.

In the main public health organizations, multiple mechanisms have been put in place for quality control. In its Strategic Development Plan for 2010–2015 the NIPH outlined 17 strategic goals, as well as a set of indicators or annual targets, against which the organization can be measured (NIPH, 2010). With a view to improving its overall management and quality of processes, the NIPH obtained the ISO 9001 standard certificate in 2015. On its web page the NLHEF emphasizes the importance of quality assurance by investments in knowledge and using accredited methods and certified systems of quality management. The NLHEF has also adopted a strategy on quality assurance, although the focus is mostly on the quality of the organization and less on the quality and impact of programmes and interventions.

In some areas of public health, such as nutrition and physical activity, where there are well developed national strategies with process and outcome indicators and action plans, as well as professional guidelines in several areas of implementation, strategies have been evaluated and the results used for the development of new strategies.

For the MURA programme, focusing on health and development, an evaluation was performed and an evaluation report published in collaboration with WHO (Buzeti & Zakotnik, 2008) that could be helpful for informing programmes in other regions in Slovenia and internationally.

In the Slovenian Network of Health Promoting Schools (http://www.schools-for-health.eu/she-network/member-countries/41/slovenia.html), evaluation is part of annual reporting on goal achievement and feeds into the planning of the next annual or biennial period.

In some other areas of public health, such as the prevention of illicit drug use and harm reduction, a part of the national programme (methadone maintenance programme and preventive services and care of drug users in primary health care centres) was evaluated to improve its performance (Trautman et al., 2007). This evaluation was financed by the Ministry of Health and performed by an external partner (the Trimbos Institute in the Netherlands) to avoid conflicts of interest in the small professional environment in Slovenia. Standards for the quality of preventive programmes in the area of illicit drugs have been developed and published by the NIPH in 2016. They serve as guidance documents for the development of programmes in schools and local communities (NIPH, 2016).

In some programmes, such as the screening programmes for cervical, breast and colorectal cancers, quality indicators such as the response rate and the quality of laboratory results are critical to programme implementation and improvement (Primic Žakelj et al., 2010).

However, there is still no comprehensive and continuous system for monitoring and improving the quality of public health services in Slovenia. While there are some quality assurance systems that help managers to improve their organizations and programmes, evaluations of the performance of different parts of the public health system and the impact of implemented programmes are not yet appropriately institutionalized.

Another challenge is the evaluation of programmes and projects implemented by NGOs. Although there are some data on the process of implementation, little is known about the impact of these programmes. Most are invented from scratch or based on perceived good practices from other countries. There are often no professional guidelines on how to implement a programme in different environments and targeted at different population groups. Indicators for measuring the impact are generally lacking.

One of the arguments used by the Ministry of Health in negotiating additional resources for public health in 2016 with the Ministry of Finance was the need to better assess the performance and impact of public health programmes and interventions that are financed from public sources. It is hoped that the findings of the anticipated evaluations will improve the organization, management and performance of public health services.

Conclusion and outlook

Public health services in Slovenia have over time developed into a strong and sustainable part of the health system, with clear roles for key stakeholders. Centralized and modernized in recent years, they have contributed to new health system developments and developed into a competent partner in intersectoral cooperation.

One of the key developments in recent years has been the introduction of new preventive and public health services, including health promotion centres, model practices and screening programmes in primary health care, focusing on noncommunicable diseases and risk factors. This has improved access for all population groups across the country to prevention and public health services.

Institutional centralization in 2013 has improved leadership and strengthened planning procedures, which accelerated cooperation with other parts of the health system and with other sectors. It also contributed to a more equal distribution of services across the country and strengthened monitoring and reporting capacities. At the same time, it was a measure to protect public health services from the implications of the financial crisis, resulting in a more efficient use of human and financial resources.

In some areas, such as nutrition and physical activity, illicit drugs and HIV/AIDS prevention, all mechanisms are in place for coordinated action at national and local levels, including strategic planning, cooperation with NGOs and other sectors, reporting and quality control, educational opportunities and international cooperation. In other areas, such as tobacco control and alcohol policy, advocacy skills and cooperation with other stakeholders (in particular national and international NGO networks) have improved substantially in recent years and contributed to the adoption of public health policies, despite aggressive counter-lobbying by interest groups.

Public health services have in recent years also improved in terms of analysing the health of the population and providing guidance to decision-makers. In some areas (e.g. tobacco control and alcohol policy) policy briefs have been developed that provide information and promote effective measures, serving as advocacy tools for NGOs and politicians.

Public health education, on the other hand, is still fragmented and the need for a strong school of public health that could train multidisciplinary professionals is becoming more obvious following recent developments and successes. Such a school could provide many professions with the opportunity to specialize in public health, fostering an intersectoral approach to public health and promoting the concept of Health in All Policies.

There is little doubt that the public health strategy that is anticipated in the 2016 National Health Plan could be a major step in strengthening public health services in Slovenia. This could entail further investments in staff development, IT support and the monitoring and evaluation of the quality and performance of public health services, which is obviously needed, also with a view to ensuring stable forward financing and capacity building. Another area that will need to be developed further is communication. Successfully communicating with other sectors and professionals, different population groups, the media and politicians is essential for using evidence and combining the strengths of all stakeholders to improve population health in Slovenia.

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