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Slovenian healthcare reform and the
prospects for innovation - an
“outsider's perspective
Dr Meir Pugatch, 15 Nov 2008
Fundamentals of Innovation in Health
• Concerns both products and services
• Relevant to the Macro level as much as it is to the Micro
level (i.e. National Innovation Strategies are also very
important)
• Generates greater value: physical, social and economic
• Rooted in market forces and incentives (Gov plays a role
but the market leads the way…)
• Long term benefits outweigh short term costs (though at
times immediate short terms benefits are also visible)
Healthcare Reforms in the CEE Region
• Dramatic change since 1989 – Post soviet era
• Healthcare reforms are part of sweeping and far reaching
changes (including flat taxes, reformed pension systems,
school vouchers, etc)
• Healthcare systems were transformed from a “command
and control style” (Semashko system) - owned by the
state, subject to central planning, and managed by similar
objectives and methods of operation – to a more pragmatic
“performance oriented” and open models.
• However, healthcare reforms in CEE countries are far
from complete and are still underway………
Common Challenges in CEE
• Medical institutions are still largely shielded from the need to
implement modern management techniques and improve
operational performance
• The provider side is still strongly concentrated and controlled
by the Gov, with a large emphasis on clinical centres and a
relative neglect of GP surgeries and other ways of providing
routine treatment for simpler cases
• Still a shortage of data on medical outcomes at the clinical
level. Such data is needed to properly evaluate providers’
performance and quality of service in general
• There is still some general hesitation (and at times resentment)
to further develop solutions that are based on public-private
partnerships (i.e. with the market)
Some Shared Objectives in CEE
• Search for a sustainable financing model
• Increasing access to medicines (sometimes this is
focused too much on controlling costs and increasing the
penetration of generics)
• Restructuring the role and relationship of different actors
in the health system
• Empowering patients
• Establishing competition between service providers
Healthcare Reform in Slovenia - Milestones
• 1889 - first Sick Fund is established in Ljubljana (emulating the
German model of social insurance - Bismarck model)
• 1918 - 1945 - establishment of a regional social hygiene
institute for prevention, primary care centres and a central
institute for hygiene and medicine
• 1945 - 1991 - gradual shift from the Social Insurance model to a
State owned and managed healthcare system. Universal
insurance is adopted (1974) and healthcare is provided via
regional centres (to our present day….)
• 1991 Slovenia becomes and independent state – and leads
significant reforms in Healthcare……
Some Key Milestones of Healthcare Reforms
• Introducing Compulsory health insurance (Law on Health Care and
Health Insurance 1992) – wide coverage of services
• Introduction of Voluntary (supplementary) health insurance (1993) By 2002 1.4 million people had taken out voluntary insurance (out of
total population of 2 million)
• Some decentralization of the health care system – also moving
towards the privatization of health care delivery ( private clinics of
physicians)
• New regulatory frameworks for medical technologies, including
pharmaceuticals (such as the Law on Medicinal Products and Medical
Devices adopted in 1999)
• As of 2000 greater focus on Improving quality and transparency and
evidence based measurements
Regulations of Pharmaceuticals – Zoom in
• Reference pricing system (85% of the average of a “basket” of
countries – Germany, France and Italy, 96% for innovative drugs)
• Health Insurance Institute (HII) responsible for the reimbursement of
drugs based on a “positive drug list” (fully reimbursed) “intermediate
drug list” (partially reimbursed) and “negative drug list” (mostly OTCs)
• Health Technology Assessment (HTA) for the purpose of evaluating the
economic value of a medicine is still nascent
• Increased tendency towards the monitoring of prescribing patterns and
practices of physicians
• Government would like to encourage the use of Generics (45% of the
market are branded generics)
• Direct to Consumer Information – not yet permitted
Implications on the Future of Innovation
Positive
• Greater tendency to work with the private sector in order
to create a financially sustainable healthcare model
(supplementary insurance, privatisation)
• Focus on transparency and quality assessment
• Shift towards evidence-based practices and effective
performance, including in the planning of health budgets
• Emphasis on capacity building and greater
professionalisation of the healthcare system
• More focus on patients’ needs and on long term goals
(prevention….)
Implications on the Future of Innovation
Negative
• Still a highly centralised system (not yet capitalising on
the advantages of decentralisation and privatisation)
• True competition between providers is still lacking (private
sector not fully utilised – hospitals, etc)
• Tendency towards cost containment of prices and
preference towards generics can deter the creation of a
stronger pharmaceutical R&D base
• Operational management of the healthcare system at all
levels still remain a challenge (though it has improved, such
as via a training programme for non-clinical managers was
launched in 2002)
Healthcare Reform - future focus…
 Creating a unified hospital system in Slovenia;
 Determination of the public health interest and proposals for
healthcare priorities;
 Categorisation of hospitals;
 Allocation of tasks between the public and private healthcare sectors
on the basis of concessions;
 Organisational standards for staff working in public healthcare
institutions;
 Development of a system of healthcare financing that focuses on
healthcare insurance holders;
 Allocation of resources between levels;
 budget guidelines;
 Investments in public healthcare institutions
 Indicators of efficiency and success of the healthcare system, healthcare
institutions and management;
 Provision of uniform complaints procedures within the healthcare
system, including the institute of a human rights ombudsman for the
healthcare system.
Health
Government
Expenditure (% of share (% of total
GDP)
health
expenditure)
Composition of
private spending
(Out-of-pocket to
voluntary
insurance)
Composition of
public spending
(social insurance
to tax funding )
Czech
Republic
7.1
89
98 : 02
90 : 10
Hungary
7.8
71
96 : 04
90 : 10
Poland
6.2
69
98 : 02
84 : 16
Romania
5.5
70
86 : 14
82 : 18
Slovenia
8.5
72
53 : 47
93 : 07
Source WHO Statistics (2008), SN 2008