Slovenian Healthcare and the Corona Crisis
Paving the way for privatization?
by Anže Dolinar
The first case of COVID-19 in Slovenia was discovered on 4 March 2020, at a time when the right-wing government led by Janez Janša was coming to power. The old government led by Marjan Šarec declared an epidemic on 12 March, one day before the new government was elected in a speedy process with little debate on parliamentary committees.
As of 8 April, out of 29,455 persons tested for the virus, 1,055 were positive. Out of those, 111 are hospitalized, 31 are in intensive care units, and 40 have died. Of those who tested positive, 219 are older people in nursing homes, and 70 tested positive among the nursing staff in these homes. To this day, 189 healthcare workers have also tested positive.
In the meantime, self-isolation measures were imposed, schools were closed, and the retail sector (but not the manufacturing sector) came to a standstill with the exception of grocery stores, drugstores, and petrol stations. Hospitals are providing only necessary care and preventive care.
There has been quite a lot of blame-shifting between the old and the new government regarding the measures taken. At the centre of the disputes was The National Institute for Public Health (NIJZ).
In the early days of the epidemic, the NIJZ was at the forefront of informing the public and directing government policy. This changed with the new Janša government, that side-lined the NIJZ and created its own crisis headquarters with its own team of experts.
Controversies continue to this day. After NIJZ director Nina Pirnat was discharged on 19 March, Ivan Eržen was named acting director. Eržen publicly criticized the government for locking down municipalities and demanding regular disinfection of all apartment buildings as inefficient and redundant.
In the meantime, the government has dismissed Eržen’s comments and replaced all four government representatives on the NIJZ board. A new director will be nominated shortly. 25 NIJZ epidemiologists defended Eržen in a public letter, claiming the government completely disregarded the experts.
On 2 April the government passed the so-called “Mega Corona Act” (Intervention Measures to Mitigate the Effects of the SARS-CoV-2 (COVID-19) Infectious Disease Epidemic on Citizens and the Economy Act). The act does little to address the health system and its issues—a perfect indicator of the government’s health policies.
In the area of healthcare, the government’s response was twofold: employing loyal staff in key positions and ruling with ordinances and decrees. Slovenian legislation allows the government to seize and use private capabilities during epidemics, but so far the government has been reluctant to do so.
The Creeping Erosion of Slovenia’s Public Health System
Slovenia’s public health system has experienced a series of privatization attempts in recent years, but still remains mostly public and in relatively good shape. Private concessionaires receive 14.45 percent of public funds.
In terms of financing, attempts were made to expand the basic benefit package, while political and media attacks on the Health Insurance Institute of Slovenia or ZZZS are a regular occurrence. This is the de facto health budget, as it collects health insurance contributions.
Complementary health insurance, which is essentially mandatory, still has not been abolished, although it is clear that it is an unjust anomaly in the system. Every citizen pays equal premiums, and without it they cannot access basic health rights. But on top of this commercial insurance companies nevertheless have huge “operating” costs they charge for.
The number of registered doctors in Slovenia stands at 6,591, while the number of nursing staff is around 20,000. Doctors have regularly threatened to exit the country’s Public Sector Salary System Act, and partially succeeded in a few aspects.
Public-sector doctors are allowed to work for another healthcare provider with the permission of the director that employs them. If the director does not reply to their request within 30 days, consent is considered granted. In addition, in some cases doctors are allowed to work on civil law contracts, which are favourable as less contributions and taxes are incurred.
Another bypass was provided by the Constitutional Court, which declared in 2018 that concessionaires in healthcare are allowed to use their surplus as they please and are not obligated to return funds in the health system as the Health Services Act predicted. Concessionaires are paid the same amount for health services as public institutions, but are not obliged to follow public procurement rules and can employ staff in a more flexible manner.
The most acute problem in recent years has been a lack of general practitioners. Tenders for specializations have long been in the domain of the Medical Chamber of Slovenia that acts with a clear class agenda, encouraging privatizations and regularly attacking any given government and especially the ZZZS. Tenders for specializations of general practitioners are now back in the domain of the Health Ministry, but students of medicine are reluctant to apply.
Huge problems are also emerging in terms of nursing staff. The restructuring of higher education and political interventions under the Bologna Process spawned a deep division within the nursing workforce; between registered nurses and associate professional nurses—those with nursing competences and qualifications, and those without.
Some nurses with years of experience and knowledge are not allowed to perform certain tasks, while others with higher education are, but do not know how to practically apply it. This division was a disciplinary measure that fragmented the labour force and allowed the ruling class to keep wages in the sector low.
Many of those infected with COVID-19 come from nursing homes, which have become the epicentre of the outbreak. It is symptomatic that nursing homes employ underpaid nursing staff, that the state completely stopped building new homes over 15 years ago, and that the prices of care keep rising.
In addition, concessionaires are allowed to charge even more than public homes. The result is 11,000 people waiting for admission and many of those already admitted unable to pay for their care, shifting the burden onto families and municipalities.
The number of hospital beds has fallen consistently for over four decades. In 1980, Slovenia had 695 beds for every 100,000 residents; in 2018 that figure was 444. The Medical Chamber in the meantime has continued its class agenda. Just before the corona crisis emerged, it proposed a bill to further privatize the Slovenian public health system.
Crisis as Opportunity?
The new government’s coalition agreement has in many ways followed the bill that the Medical Chamber proposed in January 2020. It involves the "use of all available resources" and the reorganization of the ZZZS.
“Use of all resources” would mean the effective bypassing of the Public Sector Salary System Act and reorganization of the ZZZS. This implies a change in the way the ZZZS pays for health services and which services it pays for. The "use of all resources" would mean that the expenses of the ZZZS would increase; which would lead it to alter the rules on compulsory health insurance that define the range of rights the mandatory insurance covers.
That would mean less health services which are covered by mandatory health insurance; and consequently the reorganization of complementary health insurance into a fully marketized health insurance for those who can afford it. A perfect plan for privatization.
Government responses to the corona crisis have largely followed this recipe. The only mention of health in the intervention measures legislation was a subsidy to help capitalists. Measures state that any sick leave must be paid by the ZZZS from day one, and not from the 31st day of sick leave - as existing legislation stipulates.
This relieves the capitalists of paying for sick leave, but effectively place a huge burden on the ZZZS. The latter is not allowed to borrow money and does not have a safety net in the form of emergency budgetary financing (like the Association of the Institute of Pension and Disability Insurance of Slovenia has).
The intervention measures also stipulate that public employees (health workers in the public sector) can be relocated without their consent. As mentioned above, other measures operated on the level of decrees and ordinances. The most important one was confirmed on 31 March and states that relocated public health workers and concessionaires are to be given new contracts for the relocated tasks due to the corona crisis.
Concessionaires are not public employees, but are by law obliged to participate in ensuring continuous emergency healthcare. Now they are to be given civil law contracts, which threatens to become the new normal. On 8 April, the Medical Chamber launched another attack on the ZZZS stating that private doctors are willing to work and help, but the ZZZS would not pay them.
As far as testing is concerned, the government of Janez Janša changed the methodology and for a while fewer tests were performed. This eventually changed, and now Slovenia is testing more with a focus on healthcare workers and risk groups. Slovenia is doing fairly well as far as the crisis is concerned, but this has much to do with the strength of the existing public health system and less with the policies of the current government. One could say that Slovenia is doing well not because of the government measures but despite them.
The crisis has shown in Slovenia, as it did elsewhere, that marketization and privatization of health systems is misguided, inefficient, and indeed dangerous. Health is not a commodity. Progressive forces should be wary that this crisis might bring further marketization, implementation of public management approaches in hospitals, and further outsourcing of staff—rather than the other way around.
In the face of the epidemic, it is obvious that private healthcare is useless. Progressive forces must show that it is even more useless when there is no epidemic.
Anže Dolinar is a philosopher and an assistant for health and pension policies for the Levica parliamentary group. This article first appeared on the rosa luxemburg stiftung Website. Reproduced with permission.