Health Care System for Children and Adolescents in Slovenia

Health Care System for Children and Adolescents in Slovenia Mojca Juri
ci
c, MD, PhD1, Polonca Truden Dobrin, MD, MSc1, Sonja Paulin, MD1, Margareta Seher Zupan
ci
c, MD2, and Nata
sa Bratina, MD, PhD3 Slovenia’s health system is financed by a Bismarckian type of social insurance system with a single insurer for a statutory health insurance, which is fully regulated by national legislation and administered by the Health Insurance Institute of Slovenia. The health insurance system is mandatory, providing almost universal coverage (98.5% of the population). Children and adolescents have the right to compulsory health insurance as family members of an insured person until the end of their regular education. Slovenia has a lower number of physicians per capita than both the European Union and the Central and Eastern Europe countries. Slovenia is facing a workforce crisis, as the number of health professionals retiring is not adequately being replaced by new trainees. There is also a net deficit of nurses with university and college degrees. Physicians working with children and adolescents in primary level have a 5-year specialization in pediatrics. Slovenia tends to be in line with the goals for the development of pediatric health care on a primary level in European countries, which are to maintain the achieved level of quality, better and equitable access, and delivery of services, aiming to reduce inequalities in health of children and adolescents and provide for every child and adolescent in the best way possible. (J Pediatr 2016;177S:S173-86).

S

lovenia is a Central European country with an area of 20 273 km2. The estimated population was 2.06 million in 2013, 50% of whom live in urban areas. The capital of Slovenia is Ljubljana, which has a population of 258 873. Slovenia has a low population density (101/km2).1 Slovenes constitute approximately 83% of Slovenia’s population. Hungarian and Italian ethnic groups are considered minorities with rights protected under the Constitution. Its neighboring countries are Austria to the north, Hungary to the east, Italy to the west, and Croatia to the south and southeast. Slovenia declared its independence from Yugoslavia on June 25, 1991. The number of births in Slovenia declined in the period 1990-2003 but has slightly increased since then. In 2012, the population growth rate was
0.18%, and the total fertility rate was 1.6 births per woman. Between 1981 and 2004, the proportion of children in the age group between 0 and 14 years decreased from 23% to 14%. Slovenia is among the European countries with marked aging of the population. The proportion of people older than 64 years of age is 17%. The median age of the population is 43.1 years (European Union [EU]-27: 41.2 years [2011]; EU-27 member states include: Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden and the United Kingdom). Life expectancy at birth was 77.1 years of age for men and 83.3 years of age for women in 2012 (Table I).2

Economy and Political Context The Republic of Slovenia is a parliamentary representative democratic republic. After gaining independence in 1991, the political environment has implemented various economic and social sector reforms. After 1992, Slovenia had continuous economic growth, supporting the overall convergence process. It became an EU member on May 1, 2004, and entered the Euro zone on January 1, 2007. During the last few years, the global economic crisis has had a major impact on the Slovenian economy. The level of GDP per capita in purchasing power parity, used to monitor the realization of the central economic goal of Slovenia’s Development Strategy (2005-2013), has declined. GDP per capita PPS reached 91% of the EU-27 average in 2008 but has remained at 84% since 2010. Unemployment increased from 6.5% in 2008 to 8.2% in 2013 according to the Labor Force Survey (Table II).3 Approximately 17.5% of residents have completed tertiary education, and EU European Union GP HIIS MoH NIP NIPH T1DM UCH UMC WHO

General practitioner Health Insurance Institute of Slovenia Ministry of Health National Immunization Program National Institute of Public Health Type 1 diabetes mellitus University Children’s Hospital University Medical Centers World Health Organization

From the 1National Institute for Public Health, Ljubljana, Slovenia; 2Health Care Center Velenje, Velenje, Slovenia; and 3University Children’s Hospital, Ljubljana, Slovenia Please see the author disclosures at the end of this article. 0022-3476/$ - see front matter. ª 2016 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpeds.2016.04.054

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Table I. Statistical changes in the Slovenian population in the last 22 years Total population (in millions) Population 0-14 y (%) Population over 65 y (%) Annual growth rate of population (%) Population density per km2 Average family size† Average age of woman at first childbirth (y)z Fertility rate-births per woman Birth rate (per 1000 people) Death rate (per 1000 people) Age dependency ratios (population 0-14 y:15-64 y) Total age dependency ratio (population 0-14+y >65 y:15-64 y) Proportion of urban population* Proportion of single parent households†

1990

1995

2000

2005

2012

1.998 21 11 0.1 98.5* 3.07 23.9 1.5 11.2 9.3

1.989 18 12 0.0 98.1* 25.0 1.3 10 10 26.7 44.1 -

1.999 16 14 0.2 98.3 2.8 26.5 1.3 9.1 9.3 23 42.8 50.8 18.7

2.001 14 16 0.2 98.8 27.8 1.3 9.0 9.4 20.4 42.2 51.0 -

2.058 14 17 0.3 101.4* 2.5 28.7 1.6 11 9 20.8 45.1 50.0 25.2

50.4 17.7

*SORS http://www.stat.si/letopis/2013/04_13/04-02-13.html. †Population census 1991; 2002; 2011. zPerinatal Information System of the Republic of Slovenia. Sources: World Development Indicators database, WHO HFA database, EurStat, UNHDP.

83% of adults 25-65 years of age have a high-school diploma. Among the employed population, 30% have tertiary education, and 15% of the unemployed also have tertiary education. In both the employed and unemployed, approximately 60% have completed upper secondary education.4 The at-risk-of-poverty rate declined in the period 19972003 but has increased significantly since 2010. In 2012, the at-risk-of-poverty or social exclusion rate was 19.6% (EU-27: 24.8%) and 16.4% among children and adolescents 0-17 years of age (EU-27: 28%).5 According to 2012 data, 13.5%, or approximately 271 000 people, lived below the at-risk-of-poverty threshold, 133 000 (7.5%) were severely materially deprived, and 118 000 (6.6%) were living in households with very low work intensity.5,6 The severe housing deprivation rate for young people was 30.4%, and the overcrowding rate for children (0-17 years of age) was 17.9%. Total health care expenditure, as a percentage of GDP, was 9.4% (EU-27: 9.8%) and 8.9% in 2011.7 Public spending on health and health care has stagnated since the end of the 1990s. Complementary health insurance schemes account for approximately 60% of private expenditure. These schemes currently represent 15% of all health care expendi-

ture. The remaining private expenditure is due to out-ofpocket payments for medication and services.

Child Health and Well-Being Status Changes in the state of health of children and adolescents in Slovenia have been observed, with risky behavior, mental health problems, and unhealthy lifestyle choices determining current health needs (Figure 1). Maternal and neonatal health care result in low mortality rates among infants. Approximately 6% of singletons are premature. Perinatal causes and congenital anomalies are the predominant causes of infant mortality. From 1 to 4 years of age, neoplasms and diseases of the nervous system are the leading causes of death. The percentage of low birthweight infants is approximately 6%.8 There are significant differences in perinatal health indicators related to the mother’s education.9 Injuries are the leading cause of death in children and adolescents 1-19 years of age, followed by neoplasms and congenital anomalies. Traffic accidents and suicide are the most frequent external causes of death in young people. In recent years, an average of one child or adolescent per year has died because of violence caused by other person. In Slovenia there are around 20 suicides in a year in 14-19 year olds. The rate

Table II. GDP, employment, and poverty rate data in Slovenia for the last 22 years GDP (US $)* GDP per capita* Unemployment (% of labor force)† Youth unemployment (15-24 y) (%)† Poverty rate- total at national poverty lines (%)z Poverty rate- in children (0-15 y) (%)x Inequality measure (Gini coefficient)z

1990

2000

2005

17 381 802 758

19 979 467 790 10.900 6.9 16.8

35 717 733 757 14.369 6.5 16.0 11.6 12.1 24.6

4.7

2010 17.602

24.9

2012 45 279 487 180 17.200 8.8 20.8 14.5 13.5 25.6

*International Monetary Fund, World Economic Outlook Database, January 2014. †International Labor Organization, LABORSTA Internet Database, January 2014. zWorld Bank Development report. xStatistical Office of the Republic of Slovenia.

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Figure 1. Risky behaviors related to health in 15-year-old children in Slovenia.13

is above the EU average. Injuries in road traffic accidents are a leading cause of unintentional injury to children and young adults, and they remain a serious public health problem.10 The contribution of these to the total child and adolescent

mortality rate was 18.5% and of intentional injuries was 7.56% (EU-27: 18.2% and 5.71%, respectively). Child and adolescent injury death rates have more than halved in Slovenia since the 1990s. Compared with the 31 countries participating in the 2012 Child Safety Report Cards, Slovenia’s total child and adolescent injury mortality rates ranked 9/31 for males and 16/31 for females. Assessment of health and safety, which comprised the following components: health at birth (infant mortality rate, low birthweight); national immunization rate (measles, polio, diphtheria, pertussis and tetanus vaccine - the third dose as a measure of successful vaccination), which is above 95%; and the overall child and youth mortality rate, ranked Slovenia in sixth place among European countries with good performances.11,12 Unhealthy nutrition, insufficient physical activity, and trends in overweight are the greatest challenges facing child public health in Slovenia. Children and adolescents do not consume enough vegetables and fruits, approximately onehalf of them skip breakfast, and they consume high-calorie meals, snacks, and sweetened drinks. According to research data,14 the prevalence of overweight in children 5 years of age was 18.4% in boys and 20.9% in girls, and the prevalence of obesity was 9.0% in boys and 7.9% in girls. Regarding prevalence of overweight and obesity in adolescents, up to 31% of boys and 20% of girls among 11-year-olds were overweight.15 Among 13-year-olds, the corresponding figures were 27% for boys and 16% for girls, and among 15-year-olds, 27% and 15%, respectively.15 In the study on school boys and girls aged 7-18 from 1991 to 2011, the authors report that there were 13.3% overweight boys in 1991 vs 19.9% in 2011; overweight girls 12.0% vs 17.2%; obese boys 2.7% vs 7.5%; and obese girls 2.1% vs 5.5%.16 Only 20% of children and adolescents meet the recommendations regarding physical activity.13 Mental health disorders in children and youth, the increasing rate of psychosocial stress, along with new communication patterns and addictions, are reflected in data from different sources. Alcohol consumption is prevalent among adolescents and has substantially increased over recent years.

Table III. Life expectancy, perinatal/neonatal/infant mortality rate, and data on adolescent birth rates in Slovenia in the last 22 years Life expectancy at birth (y) Life expectancy at birth (men, y) Life expectancy at birth (women, y) Perinatal mortality rate (>1000 g) Neonatal mortality rate (per 1000 live births) Postneonatal mortality rate (per 1000 live births) Maternal mortality rate (per 100 000 live births)* Infant mortality rate (per 1000 live births) 0-5 y mortality rate (per 1000 live births) Adolescent birth rates (15-19 y)(live births/1000) Adolescent birth rates (% of all live births to mothers <20 y) Abortions/1000 live births, under 20 y % of children vaccinated against measles

1990

1995

2000

2005

69 77 8.59 5.14 3.22 7.7 (90-94) 8.36 10 17.63 5.57 701.02 91.9

70 78 7.03 3.06 2.48 12.1 (95-99) 5.53 7 8.97 5.30 1053.97 92.6

76.3 72 79 6.96 3.58 1.32 11.4 (00-04) 4.90 6 7.48 2.8 1625.98 95.2

77.6 74 81 8.63 3.10 1.05 15.0 (05-09) 4.15 4 6.04 2.01 1278.24 94

2010

2011-2012

76.4 83.3 5.83 1.80 0.72

77.5 77.1 83.3 5.19 1.11 0.55

2.52

1.66 3 4.55 1.01 1226.19 96

4.95 1.13 1346.61 95

Sources: WHO, Health for All database, URL: http://data.euro.who.int/hfadb/, Indicators: 1010, 1011, 1012; the statistical office of the European Union, European core health indicators, URL: http:// ec.europa.eu/health/ph_information/dissemination/echi/echi_en.htm; NIPH R Slovenia, Forms DEM 2–Notification of death and Death certificate and report on the cause of death; WHO, HFA-DB, URL: http://data.euro.who.int/hfadb/, Indicator: 1110. *Maternal mortality rate (per 100 000 live births).

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According to school survey data, the prevalence of binge drinking is among the highest in Europe. Smoking is practiced by 19% of 15-year-olds on a weekly basis. One-quarter of 15year-olds use or have experimented with illicit drugs, mostly cannabis (23%) and to a lesser extent, volatile substances and nonprescription sedatives and tranquilizers. Only approximately 8% reported abstinence from all legal or other drugs, and the rate of tobacco abstinence was approximately 30%.17-19 The rates of pregnancy and abortion among girls 1519 years of age have decreased over the last decade. On average, there are 4.5 births and 5.8 abortions per 1000 girls, compared with 6 births and 9.1 abortions per 1000 girls in 2002 (Table III).

Organization and Governance for Child Health Care Services Overview of the Health System Slovenia has already adopted a number of health care policy measures that are the results of effective cross-sectoral collaboration, for example, adoption of strategic and action plans in nutrition and physical activity, diabetes prevention and care program, and a tobacco control program. European and national legislation, health strategies, and pro-

Volume 177S grams offer a sufficient legal and substantive framework for the integration of health into the development and implementation of departmental policies. In 2010, the Project Group for the Health in All Policy was established at the National Institute of Public Health (NIPH) to enhance intersectoral collaboration in general, and in the following areas in particular: Slovenia’s Development Strategy to 2020, the National Reform Program (reducing poverty and social exclusion), the National Social Assistance Program for the period 2011-2020, the National Program on Road Safety 2012-2021 (particular focusing on alcohol), the National Sport Program, Resolution on the Slovenian Agriculture and Food Industry Strategic Guidelines, the White Paper on Education, Program for Children and Youth 2006-2016, as well as the new National Nutrition Policy. In February 2011, the government endorsed the outline for the preparation of Slovenia’s Development Strategy for the period 2013-2020 (Figure 2).20 NIPH is responsible for health promotion and education programs that are implemented at the primary health care level by health care professionals working in health care centers. These programs, together with the Healthy Schools Project, have become nationwide initiatives, although they operate at the level of local communities, cities, and schools.21

Figure 2. Organizational chart of the Slovene health care system. S176


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October 2016 All hospitals in Slovenia send aggregate reports (organization, bed capacity, number of hospital days, injuries, poisoning, deliveries, fetal deaths) to NIPH.

Perinatal Information System. Data on deliveries and newborns, irrespective of place of birth or professional assistance, have been collected in Slovenia since the early 1950s. Since 1987, they have been collected through the computerized Perinatal Information System of the Republic of Slovenia in all maternity hospitals. Its purpose is to assist in monitoring, evaluating, and planning perinatal health programs and to calculate perinatal health indicators. Fetal Death Information System. Data on pathologic pregnancies, ectopic pregnancies, miscarriages, and abortions have been collected since 1990. The Fetal Deaths Information System serves to monitor, evaluate, and plan health programs aimed at reducing the number of fetal deaths and to calculate reproductive health indicators. Quality Indicators. In 2010, the National Strategy on Quality and Safety in Health Care (2010-2015) was ratified by the Ministry of Health (MoH). Its implementation was based on the Manual on Quality Indicators, prepared in collaboration with the World Health Organization (WHO) and several national institutions. A list of over 70 indicators was prepared based on the quality indicators of the MoH, Organization for Economic and Cooperation and Development (Project Health Care Quality Indicators), WHO (Project Performance Assessment Tool for Quality Improvement in Hospitals), Medical Chamber (Project Quality in Health Care, Slovenia) and other institutions (ie, Nurses and Midwives Association of Slovenia). Indicators in the manual reflect health promotion, health education, and prevention (exclusive breastfeeding at discharge; immunization rates for measles, diphtheria, tetanus, pertussis, hepatitis B, influenza [>65 years of

age]; incidence of measles, pertussis, hepatitis B; smokers among the adult population [>18 years of age]; and cardiovascular diseases [percentage of population with 10-year cardiovascular risk of >20%], percentage of population with normal blood pressure, normal cholesterol, normal body mass index).

Planning of Health Professionals. Slovenia is facing a deficit of health professionals. Since the late 1990s, the health policy has translated into a steady increase in the number of physicians in Slovenia, accounting for 237 per 100 000 population in 2006 compared with 199 per 100 000 in 1990.22 There was a deficit in nurses with university and college degrees, which reached approximately 15% of the workforce. Slovenia still has a significantly lower number of physicians per capita than most EU and Central European countries. Since the 1990s, simple physician-topopulation ratios were calculated by the MoH to serve as a basis or a standard. These ratios were also used in the reimbursement schemes by the Health Insurance Institute of Slovenia (HIIS), especially at the primary care level. The process of planning health personel was coordinated with the Ministry of Higher Education and representative professional boards, in particular the Medical, Pharmaceutical, and Nursing Chambers. Training of Health Professionals Working with Children The Health Council of the MoH, in cooperation with the Medical Faculty and other institutions, proposes and monitors the implementation of health services-related professional education. Basic education, leading to a university degree for a medical doctor, takes 6 years. The number of postgraduate posts is proposed by the Medical Chamber, which is responsible for the postgraduate training programs. This is accepted and confirmed by the MoH. The Slovenian Medical Association is responsible for the content of

Table IV. An overview of the main functions and the stakeholders involved in the implementation Function/step

Main stakeholder

Other stakeholders/partners

Medical degree certification Postgraduate training posts Basic certification Registration Licensing Concessions

Medical Faculty, University of Ljubljana, SQAA MoH, Slovene Medical Association

Medical and dental posts

Medical Faculty Medical Chamber MoH Medical Chamber Medical Chamber MoH Municipalities MoH

Needs evaluation

Health Council

National Health Plan

National Assembly

NIPH Medical Chamber Health Insurance Institute Health Council Medical Chamber NIPH NIPH Health Insurance Institute MoH NIPH Health Insurance Institute Medical Chamber Slovene Medical Association

SQAA, Slovenian Quality Assurance Agency for Higher Education. Source: Albreht et al.23

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postgraduate courses, and the Medical Chamber prepares and implements the program for medical specializations. Since 2000, the area of postgraduate specialist training has been reformed and curricula have been synchronised according to the European Union of Medical Specialists guidelines for each respective specialty. Physicians working with children and adolescents complete a 5-year fellowship in general pediatrics; while before 2003 there was also specialization in school medicine for medical doctors working with children of school age (6-19 years of age). The examination commission of the Medical Chamber of Slovenia conducts the final examination and issues certificates (Table IV). In Slovenia, 5644 physicians currently are employed, 404 as pediatricians and 180 as pediatric residents. There are 243 primary care pediatricians; the remainder work in hospitals. General practitioners (GPs) and family doctors provide care for 1.5% of children 0-6 years of age and 7.7% of children 7 - 18 years of age (Table V). Training for registered nurses is provided as 3- and 4-year programs. A new curriculum for registered nurses, which started in 1993 at the University of Ljubljana, is based on the principles of primary health care, with strong emphasis on health promotion and prevention, and includes health education as a course of instruction. Currently, nursing professionals in Slovenia are studying for Bologna master and doctor degrees. Educational standards are set by the universities and the Slovenian Quality Assurance Agency for Higher Education. Qualifications are still revalidated by the MoH, as in 2007. It is on the Government’s agenda to transfer to the Nursing Board of Slovenia the competencies for registration, licensing, and auditing in nursing. Nursing is also one of the regulated professions within the EU. In Slovenia, 17 000 nurses and medical technicians currently are employed. According to WHO data, in 2008, Slovenia had 780 nurses employed per 100 000 inhabitants.24 Of these, approximately 6000 are registered nurses. Nurses obtain a license, which must be renewed every 7 years. The relationship between nurses and nursing technicians per patient is 30:70. Pediatric nurses have a general education because there is no subspecialization.

Financing Since 1992, Slovenia has a Bismarckian-type social insurance system based on a single insurer for a statutory health insurance, which is fully regulated by national legislation and administered by the HIIS. The MoH is responsible for financing health infrastructure for hospitals and other health services and programs at the national level, as well as covering for health services of persons without income. The role of local municipalities in health financing is relatively small and limited to the provision and maintenance of health infrastructure at the primary level (ie, primary health care centers, health care stations, and public pharmacies). S178

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Table V. Number of all medical doctors, pediatricians, primary care pediatricians (social pediatrics), and child and adolescent psychiatrists, Slovenia, 2013 All medical doctors All pediatricians Primary care pediatricians Pediatric neurologists Specialists in child and adolescent psychiatry

Number

Per 1000 (0-19)

4399 404 243 5 21

1.04 0.63 0.002 0.010

Source: Registry held by Medical Chamber 1.7.2013.

The health insurance system is mandatory, providing almost universal coverage (98.5% of the population). Contributions are related to employment earnings, although coverage is also provided for nonearning spouses and children of contributing members. Compulsory health insurance contributions constitute 13.45% of their gross income and are shared between the employer and the employee. The employer additionally pays for workplace-related injuries and occupational diseases. Primary health care services within the public health care network are paid for by a combination of per head and fee-for-service payments, and outpatient specialized care is paid by fee-for-service only. Payment for acute inpatient care is based on diagnosisrelated groups, whereas payment for nonacute inpatient care is calculated by number of bed days per stay. Voluntary health insurance premiums and household outof-pocket spending represent private sources of funds and accounted for approximately 28% of the total health care funding in 2012. In the context of the gradual reduction in health financing by public entities, in 2006, 85% of the population contributed to voluntary complementary health insurance schemes, which cover patients’ copayments. In 2012, approximately V3141 million was spent on health care in Slovenia, amounting to 8.9% of GDP in 2012. Public health expenditure comprised 6.4% of GDP. Approximately one-quarter of current health expenditure was financed from private sources in 2012. Rights Arising from Compulsory Health Insurance Health policy, the legal and financial regulation of health care for children and adolescents, is outlined in the Resolution on National Health Care Plan 2008-2013. Slovenia25 assured the basis for an equitable, accessible, high quality, responsive,

Table VI. The number of hospital beds available for children (0-19 years of age) 1990 1995 2000 2005 2010 2012 Pediatric clinic and pediatric wards* 941 730* 663* 582* 523* 530* Average length of stay 4.8 4.4 4.0 5.6 3.0 Average bed occupancy rate 57.5 58.1 52.4 62.2 55.2 Data on hospital beds for the pediatric population were prepared on request. *Data on hospital beds for the pediatric population; source: NIJZ.


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Table VII. The current childhood immunization schedule in Slovenia Age Birth 3 mo 4-5 mo 6 mo 12-24 mo 5-6 y 8y 16-18 y

BCG (for TB)

Diphtheria tetanus

Poliomyelitis

Pertussis (acellular)

Hib

Hepatitis B

MMR

†

Yes*

Yes Yes Yes Yes Yes

Yes Yes Yes Yes

Yes Yes Yes Yes

Yes Yes Yes Yes Yes

Yes Yesz

Yes Yes

Yes

BCG, bacillus Calmette-Guerin; Hib, Haemophilus influenzae type b; MMR, measles, mumps, and rubella; TB, tuberculosis. *Recommended for newborn infants of immigrant families coming from countries with a higher prevalence of tuberculosis within the last 5 y. †Recommended for infants born to mothers with hepatitis B virus surface antigen. Administered in 4 doses (0, 1, 2, 12), starting within 12 hours postpartum simultaneously with hepatitis B immunoglobulin. zOnly tetanus.

and efficient health care for children and adolescents in the Constitution and legislative regulation. Children and adolescents have the right to compulsory health insurance as family members of an insured person until the end of their regular education. Compulsory insurance covers the full cost of the following preventive health care services: (1) preventive examinations of infants, preschool children, school children, adolescents, full-time students, women in relation to pregnancy, and other adults, all according to the program with the exception of preventive examinations related to the workplace, which are paid by the employer; (2) early detection and prevention of diseases, in accordance with the program; health care services for women concerning family planning counseling, contraceptive measures, pregnancy, and childbirth; cervical cancer; breast cancer, and colon cancer screening program; (3) prevention, detection, and treatment of HIV infection and communicable diseases for which the measures to prevent spreading are provided by the statute; (4) mandatory vaccination, immunoprophylaxis, and chemoprophylaxis in accordance with the program; (5) home nursing visits; and (6) prescription medications. One of the parents (guardian, or person who cares for a child or an adolescent) has the right to a maximum of 14 days of paid absence from work (sick leave) to nurse a sick child or adolescent. For children less 7 years of age, the maximum paid absence is 30 days. In cases of severe disease or serious deterioration in a child’s or an adolescent’s health (up to 18 years of age), one parent or guardian has the right to paid absence for a maximum of 6 months. Infants have the right to preventive examinations at 1, 3, 6, 9, 12, and 18 months and 3 and 5 years, including vaccinations (following the National Immunization Program [NIP]) and Denver developmental tests, psychological testing at 3 years of age, and analysis of speech defects at 5 years of age. Preventive dental care starts at 1 year of age. Children have the right to further examinations before school enrollment and every 2 years during schooling, including vaccinations and health education. Children in special educational programs (1% of the population be-

Health Care System for Children and Adolescents in Slovenia

tween 7 and 19 years of age) are entitled to annual examinations.26

Physical and Human Resources Hospital treatment is provided by 29 hospitals, 3 private and 26 public. There are 2 University Medical Centers (UMC; Ljubljana and Maribor), 10 general hospitals (8 regional), 3 clinics, and 12 special hospitals with 9349 available beds in 2012. As data are available only at the level of specialty, there are 530 beds for the pediatrics specialty. There are also beds for children and adolescents in other hospitals: general surgery, infectious diseases, otorhinolaryngology, orthopedic surgery, ophthalmology, and dermatology. The average length of stay in most hospitals is less than 5 days, with the shortest being 2.2 days at the pediatric clinic in Ljubljana (Table VI).

Provision of Services Public Child Health Care Services The basic model of child and youth health care services in Slovenia is based on specialists in pediatrics or in school medicine working in a team with a nurse and other health care professionals at the primary level. Children and adolescents have the statutory right to a personal pediatrician or specialist in school medicine until 19 years of age. School health services, as a type of health care, have a long tradition in Slovenia. The school health service comprises preventive and curative medicine, counseling, and health education.27 Every school has a nominated specialist in school medicine or a pediatrician who is responsible for preventive examinations and vaccinations in school-aged children. The doctor also assists in school events involving health issues, is a member of the team that inspects school buildings and their surroundings to advise and propose measures for the prevention of possible harmful effects on children’s health and to prevent injuries, and supports the organization of school meals. The doctor works together with the school counseling service, the class teacher, and the school principal.

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The role of the personal pediatrician can be, in exceptional circumstances, carried out by a GP with additional qualifications in child and adolescent care, or by a family doctor, if other arrangements are not possible. Pediatricians involved in curative care also organize preventive activities (systematic checkups, vaccinations), participate in health counseling, and work hand-in-hand with kindergartens and schools. Personal dentists must be qualified for dental care of children. Girls have the statutory right to visit a personal gynecologist. Vaccination The MoH is responsible for the annual NIP, which is prepared by NIPH in cooperation with pediatricians, infectologists, and pulmonologists. It defines mandatory and recommended vaccinations for newborn infants and children, school children and adolescents, people exposed to communicable diseases at work (vaccination against hepatitis B and tick-borne encephalitis), international travelers (yellow fever), and groups at risk for hepatitis B, influenza, and pneumococcal infection. NIP determines the chemoprophylaxis or postexposure prophylaxis for people exposed to meningococcal meningitis, meningitis caused by Haemophilus influenzae type b, HIV, cholera, tuberculosis, influenza, avian influenza, whooping cough, and scarlet fever. Only vaccines approved by the NIP can be used in Slovenia. The NIP is valid for the entire country and is coordinated by the national and 9 regional coordinators. Immunization rates are still low in some ethnic groups. The immunization program for children and adolescents is mostly mandatory and free of charge (Table VII). The compliance rate is 95%. A medical exemption request can be submitted to a committee at the MoH. The immunization program is performed during the Preventive health checkups to reach the majority of children and school children with maximum effect at minimal additional costs. Nonattenders are additionally invited for immunization by their pediatrician. According to vaccination indicators monitored by the WHO, Slovenia ranks among European countries with good vaccination rates. Vaccine coverage of preschool children is 94%, and coverage of school children is approximately 98%. Voluntary vaccination of young girls against human papillomavirus with quadrivalent vaccine was included in the national vaccination program in autumn 2009. The population of 12-year-old girls receive the first dose of vaccine during their regular preventive health checkups. Currently, the human papillomavirus vaccination rate is 55% (Table VII).28 Patient Clinical Pathways The first contact for a child with suspected asthma is the primary care pediatrician, who prescribes asthma medication on an as-needed basis and refers him/her to the secondary level, where the diagnosis is confirmed. The child and his parents receive an individually written action plan. “Asthma school,” ongoing patient education, and regularly scheduled follow-up visits to reassess asthma conS180

Volume 177S trol, adjust therapy, and promote adherence to medication are crucial for long-term success. A variety of assessment tools are used to provide a consistent and objective assessment of asthma control (Asthma Control Test, Asthma Therapy Assessment Questionnaire). The advice is personalized at each visit, and there is a weekly class for the group of parents and children. Almost all the primary care pediatricians in Slovenia have been trained in the Asthma School program, and they educate their patients according to those instructions, from the time of diagnosis onward. Asthma School, the Slovenian national educational program for primary care pediatricians, is organized annually by pediatric pulmonologists at the University Children’s Hospital (UCH) in Ljubljana. It has reduced emergency visits and hospitalizations due to exacerbations of acute asthma over the last 10 years.29,30 Primary-First Contact Care The pediatric service at the primary level is mostly provided by pediatricians, the majority of whom work in public health care centers or in private practice, which is a part of the public health care network. In isolated areas with a low number of children or in areas with a shortage of pediatricians, GPs care for the pediatric population. There are no limitations on access to a child’s personal pediatrician or GP. A pediatric team is made up of a pediatric specialist, a registered nurse, and 0.5 registered nurses with a university degree. On average, one pediatric curative team cares for 2200 people (or 2800, depending on the ages of the children). At the primary level, 369 physicians work in the pediatric health care services, of whom 243 are pediatricians or school medicine specialists. The rest are licensed in family medicine, general medicine, and other specialties. Currently, pediatricians and school medicine specialists care for more than 90% of children 0-19 years of age. There are 3 types of pediatric teams: those who care primarily for preschool children 0-5 years of age, those who mostly care for school children 6-19 years of age, and mixed preschool and school teams. Preschool teams offer primary curative and preventive care for children as well as immunization program. School teams provide preventive programs and immunization program for all school children in a given school but treat only the patients who have chosen them as their personal physician. Preschool and school teams allocate two-thirds of their working time to curative care and onethird to preventive programs. Preventive examinations aim to monitor the child’s mental and physical development and detect risk factors for certain diseases, mental disorders, etc. At the same time, health education takes place, with the topics being selected according to the age group (adolescence and practising safe sex, healthy nutrition, etc). Outpatient Hospital Care The accessibility and quality of outpatient care for children is traditionally good throughout Slovenia. Quality assurance is performed by institutional controls, but no generally accepted quality indicators are collected at the national level.
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October 2016 Establishment of the first community-based outpatient clinics has been achieved within the framework of admitting private initiatives and allowing for privately organized outpatient clinics, which have been included in the state welfare system since 1992. Inpatient Care

Secondary Level. Patients are referred to hospital accident and emergency department from primary care pediatricians or GP/family doctors. Inpatient care for pediatric patients is available in 9 pediatric wards attached to regional or local general hospitals. All hospitals were established by the government and are part of the public health care service. Most of the wards are organized as both in- and outpatient departments. Twenty-four-hour emergency consultant or outpatient services are available. Outpatient services operate on weekdays and cover various subspecialties. Pediatricians also cover the neonatal departments in maternity wards. An average pediatric ward has up to 30 beds for basic pediatric diseases and up to 7 beds for pediatric surgery. The average in-hospital stay is 3 days. Day-only hospitalizations are included in the system of hospital care.

SUPPLEMENT period (eg, weekdays after regular working hours from 7:00 p.m. to 11:00 p.m., Saturdays and Sundays from 7:00 a.m. to 4:00 p.m.). Outside of these hours, GPs or pediatricians who participate in the general emergency medical service, manage urgent pediatric cases. The pediatric emergency medical service in Ljubljana is available at all times in primary care health centers during the day and in a centralized hospital unit during the night, weekends, and holidays. Care is provided exclusively by pediatricians and specialists in school medicine, and only exceptionally by physicians with a postgraduate course in child and maternal health. Trauma centers manage medium- and larger-sized traumatic injuries and smaller injuries requiring surgical care. The Clinical Pathway for a Child with Fever and Rash and a Suspected Meningococcal Infection During regular working hours, the primary care pediatrician will be the first to examine the child. In a triage process, the degree of urgency is determined. If signs are suspicious of meningococcal infection, the child will be immediately transported to the nearest hospital. Appropriate antibiotic treatment is commenced before emergency transportation. Helicopter transportation for emergency cases to UCH in Ljubljana was started in 2012.31,32

Tertiary Level. Two UCHs are located in the 2 biggest towns (Ljubljana and Maribor). Inpatient, day-only hospitalization, and outpatient services are available. Pediatric intensive care units are an integral part of UCHs. On the pediatric wards, parents stay in the hospital with the child. The cost of accommodation and meals is completely covered by the insurance company for a parent of a child up to 5 years of age. Parents of older children have to pay for their hospital stay. In every pediatric clinic, there is a hospital school and, as part of our child-friendly service; there are playrooms, teachers, tutors, and voluntary activities, such as Red Noses (an animation program for sick children, that started in the US), animal-assisted therapy, etc. Although there is a noticeable decrease in the hospital admission rate for children and a reduction in the number of hospital days, the hospital admission rate could be lowered even further. To reach this goal, it will be necessary to reinforce primary health care of children and adolescents in terms of staff and establish efficient urgent medical services with 24-hour accessibility to pediatricians. Greater emphasis should be placed on day-only admissions.

Emergency Care In Slovenia, the emergency medical service is set up according to the number of pediatricians in a defined area and the organization of emergency medical care in general. There are 3 forms of children’s out-of-hours health care. GPs manage most of the medical emergencies involving children outside of regular working hours. Pediatricians are included only if they take part in the emergency service, which covers the whole population. In some primary care clinics, there is a special children’s emergency medical service for a limited time Health Care System for Children and Adolescents in Slovenia

Chronic Diseases and Long-Term Conditions Because Slovenia is a small country, children with many chronic diseases and conditions receive centralized health care. For rare diseases and conditions, such as severe immunodeficiencies, resistant epilepsy, rare neurometabolic conditions, cancer, hemophilia, endocrine and metabolic diseases, cystic fibrosis, inflammatory chronic bowel diseases, and congenital heart diseases, as well as patients dependent on dialysis, the main in- and outpatient center is the UCH in Ljubljana, where multidisciplinary medical teams care for children and adolescents with these specific conditions. For some conditions, team management is also available at the UCH in Maribor. Type 1 diabetes mellitus (T1DM) is one of the abovementioned chronic diseases. Prior to 1955, children with newly diagnosed disease were treated by internal medicine physicians in general hospitals throughout Slovenia. Since 1955, from the time of diagnosis, children commence their treatment in Ljubljana. Until 1991, a small percentage of them received medical counseling, follow-up and treatment in the Maribor and Slovenj Gradec General Hospitals. Nowadays, all children (650 at present) with T1DM and type 2 diabetes mellitus are treated at the UCH up to the 25 years of age. The current standardized incidence of T1DM in Slovenia is 12.1/100 000 children, with an annual increase of 3.77% (6% in children under 6 years of age).33 Medical treatment and support is well organized. After diagnosis, treatment and care are structured and focused on outpatient care. Only at the time of diagnosis do children or adolescents and their family members stay in hospital for 5-7 days for diabetic education. After the first hospitalization, most of the medical care is given on an outpatient basis. S181

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A multidisciplinary team, including pediatric endocrinologists, certified nurse educators, psychologists, dieticians, and a social worker care for children, adolescents, and young adults with T1DM. The same structured education and management plan is provided for children and their parents as well as for professional caregivers involved with children with T1DM in kindergarten, schools, and sports activities. The patients’ organization organizes regular annual educational meetings and summer camps, provides information about diabetes available on a website (www.sladkorcki.si), and produces printed annual publications.34 The continuous subcutaneuous insulin infusion (insulin pump) was introduced as a standard treatment modality with public reimbursement in 2000. At present, more than 80% of children are using pumps, and 10% are also using continuous glucose monitoring systems, which are reimbursed for children less than 7 years of age. The average metabolic control is good (hemoglobin A1c 7.75% in 2011), and the acute complication rate for severe hypoglycemia and ketoacidosis is low.35-37 Parents and medical teams from all over Slovenia have a 24/7 emergency telephone line that provides support and advice in critical situations and helps to stabilize children with newly diagnosed T1DM for transportation to UCH. Support and consultations are offered for patients, families, caregivers, and primary health care pediatricians.38 The majority of patients with epilepsy are treated and followed by the specialized epileptology outpatient care system, but up to one-quarter of all patients are drug resistant and are expected to need hospital care more frequently because of additional diagnostic procedures and treatment. The basic diagnostic work-up and first evaluation of pediatric epilepsy patients is provided in 2 medical centers, UCH in Ljubljana and UCH in Maribor. The group of drug-resistant patients is expected to require additional psychological, psychiatric, social, and educational interventions, including possibly institutional care or individualized school programs, depending on associated problems. These drug-resistant patients are referred to a single tertiary Center for Epilepsies of Children and Adolescents (UCH in Ljubljana), which provides further diagnostic work-up and treatment and selects presurgical candidates. Epilepsy surgery (pediatric and adult) is not available in Slovenia; candidates are referred for surgery to selected pediatric epilepsy surgical centers in Germany and France.39-43 Neurodevelopmental Specialist Services Within the primary health care setting, there is a network of neurodevelopmental specialist services aimed at early detection, treatment, surveillance, and follow-up of children with neurodevelopmental problems and providing support for their families. The specialized teams care for every child with a possible developmental problem; mostly within the first year of life, and continue management until 19 years of age. The team consists of a pediatrician with additional qualifications in developmental pediatrics and pediatric neurology, a nurse, 2 neurophysiotherapists, 0.5 S182

Volume 177S occupational therapists, and 0.5 speech therapists. The network provides care for 20 000-23 000 children 0-18 years of age. Important quality criteria for neurodevelopmental services are: (1) early commencement of treatment, preferably in the first months of life; (2) extended indications (increasing percentage of children with mixed disorders, autism); (3) integration of children who would have previously been assigned to other services; and (4) parents’ broader knowledge as well as expectations and demands. A holistic approach would also require the team to include a psychologist, speech therapists, special caregiver, and a social worker. In some areas, these professionals are employed in mental health services, and their cooperation is a matter of individual choice. In Slovenia, an increasing number of children with serious developmental problems remain in home care while being treated at neurodevelopmental outpatient services, which results in a growing demand for these types of services. Safeguarding-Child Protection Treatment of victims of violence by health professionals is regulated by the Law on Prevention of Domestic Violence and the Rules of Procedures in dealing with domestic violence in the implementation of health activities.44 In accordance with this law and its regulations, professionals and health care workers are obliged to perform the necessary procedures and measures to protect victims and provide appropriate assistance. Everyone, but in particular health care professionals and child care and educational personnel, is required by law, notwithstanding confidentiality, to inform the Center for Social Work, the police, or the public prosecutor’s office, when child abuse is suspected. Palliative Care Palliative care should be an integral part of primary, secondary, and tertiary health care. It is a basic right of all children and adolescents when needed. In 2011, the MoH approved a program in the Department of Clinical Hematology and Oncology, UCH in Ljubljana that saw the introduction of special palliative care for children and adolescents at the tertiary level and the formation of a multidisciplinary team for the management of children and adolescents with fatal diseases or those causing premature death. Today, pediatric palliative care has become an integral part of the National Palliative Care Program. The first step, or the short-term goal of the adopted program, was the palliative care of terminally ill and dying children in Slovenia by the tertiary level palliative team, preferably in the child’s home. The mission of this team is not to prevent or offset the moment of death, but to ensure that death is peaceful and without suffering as far as possible. The pediatric palliative care team consists of a pediatric hemato-oncologist with an interest in palliative medicine, a registered nurse, and a clinical psychologist. Other profiles are also included. A pediatrician with a specialization in palliative medicine is planned for the future.
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October 2016 There are no planned hospital beds exclusively for palliative care. If a child or adolescent is hospitalized, the permanent members of the team meet daily, share information on the patient, and document all relevant findings. Other professionals are invited according to the needs of the patient. When the patient is in home care, a tertiary institution specialist team visits the home, and communicates with the child’s doctor at the primary or secondary level or with the hospice and Centers for Social Work. Mental Health Care The mental health care of children and adolescents in Slovenia is divided between health, social, family, and educational services. Health services provide preventive, curative, and rehabilitation care, which are carried out in the course of primary, secondary, and tertiary health care and are geographically distributed throughout the country. Within the framework of these services, specialists in various fields (nurses, social workers, speech and language therapists, special educators, occupational therapists, physiotherapists, clinical psychologists, pediatricians, and child and adolescent psychiatrists) are employed.

Specialist Child and Adolescent Psychiatric Care. There are 25 child and adolescent psychiatrists working in Slovenia who manage 46 hospital beds in 3 separate hospital wards. Child and adolescent psychiatrists, together with clinical psychologists, constitute a team. Together they organize diagnostic examinations and curative care. There is still no high-security ward for children and adolescents in Slovenia with severe mental disorders. In 2013, 45 clinical psychologists and 16 psychologists (without specialization) worked with children and adolescents. This makes a low average of 6 psychologists per 100 000 population, which is below the global average. Most of these work at the primary level (health care centers, private psychologists in the national network), and the remainder work in hospitals. A team approach to the treatment of mental and behavioral disorders in Slovenia has operated since 1950, reaching its climax in the 1990s with good results. With the growing need for psychological evaluations and therapy, the existing number of psychologists is no longer adequate. Clinical psychologists seek to strengthen the network of psychological screening and treatment options for children and adolescents and to provide early and rapid access to support for children and young people in their local area. Dental Care Dentists (doctors of dental medicine), as primary dental care providers, are registered by the Medical Chamber of Slovenia. Most dentists are graduates of the 6-year program of Dental Medicine in the Faculty of Medicine, University of Ljubljana. Primary dental care for children and adolescents is undertaken either in community health centers or in single practices (rarely group practices) of dentists who are contracted Health Care System for Children and Adolescents in Slovenia

SUPPLEMENT for services by the HIIS. There are approximately 280 dentists who work as providers of primary dental care for children and adolescents. As a rule, parents can choose freely between these providers. Typically, their services comprise complete basic oral health care (eg, systematic dental check-ups), preventive services (eg, topical application of fluoride varnishes), diagnosis and treatment of caries and its consequences, periodontal diseases, noncomplicated traumatic dental injuries, etc. Specialists in pediatric and preventive dentistry are trained and educated in a 3-year postgraduate program conducted primarily in the Department of Pediatric and Preventive Dentistry, UMC Ljubljana. The program is coordinated by the Medical Chamber of Slovenia and follows the guidelines of the European Academy of Peadiatric Dentistry (1997). Specialist orthodontic care for children and adolescents is provided by approximately 80 specialists. There are several preventive oral health interventions for children and adolescents delivered on a population-wide basis. Oral health promotion and education activities by pediatric and preventive dental specialists are primarily focused on the prenatal period (parenting classes) and early childhood. In school children, the location of several dental clinics on school premises facilitates preventive activities of primary dental care providers. This is supplemented by oral health promotion and educational activities performed by approximately 90 oral health educators (mostly registered nurses) in kindergartens, schools, and dental surgeries, focusing on oral hygiene and healthy nutrition. To collect, analyze, and report data on services provided and the quality of dental care, an information system is being prepared, following the guidelines developed through the European Global Oral Health Indicator Development Project.45,46 Specific Vulnerable Child Populations

Maternity and Neonatal Care. In Slovenia, 99.9% of infants are delivered in maternity hospitals. The obstetrics team comprises a midwife and a specialist in gynecology and obstetrics, who takes responsibility for the team. There are 14 hospital centers and wards, 2 of which are at the tertiary level and provide for neonatal intensive care unit. Most women with multiple gravidity or premature labor (transport in utero) are referred to one of these specialized centers. During a normal pregnancy, every woman has the right to 10 preventive examinations, 5 by gynecologists and 5 by midwifes or nurses. Preventive services include laboratory tests: hemogram, blood group, Rhesus factor D, Indirect Coombs test, toxoplasmosis, syphilis, hepatitis B tests, urine examination, and oral glucose tolerance test for women at risk of diabetes. There are also two diagnostic medical sonography examinations, in early pregnancy and at 20 weeks. Women 35-37 years of age have the right to the Down syndrome screening test (nuchal translucency scan or hormonal test) and those over 37 years of age, to amniocentesis or chorion S183

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biopsy and karyotype. The latter is also available to those who have positive screening result for congenital anomalies. Women have the right to a preventive examination by a gynecologist following delivery and to 2 home visits by a health visitor. For newborns and infants under 12 months of age, 6 home visits by health visitors are offered. Newborns receive a preventive examination including transient-evoked otoacoustic emissions and screening for phenylketonuria, hypothyroidism, and hip dislocation in maternity ward/hospital. Some cases of maternal death have still been reported in recent years. A special multidisciplinary working group has been appointed by the MoH to analyze maternal mortality by individual investigation of all cases of maternal death. The data sources are death certificates and reports on the cause of death of women in the fertile period, as well as perinatal information system and Fetal Deaths Information System, which is very useful for identification of additional causes of death. The working group requests and collects medical documentation from health care providers and afterward performs analyses according to a uniform protocol. The report, including recommendations for health sector and community actions, is then prepared.

Major Reforms to the Health System The basis of the health system reform is similar to that of other EU members, and there has been a high degree of consensus recently. The most current political and developmental issue is managing the influence of the aging population and other long-term trends on public financial sustainability of health and social care systems. Several initiatives in the last decade have led to partial solutions, and now the present government will also form their own initiatives.

Health System Assessment Recently, the public health view has been summarized and key issues have been discussed. The advantages of the current arrangements for preventive health care for children and adolescents in Slovenia are the universal coverage of the population, early identification of health problems, and an integrated service for preschool children, school children, and adolescents by pediatricians at the primary level. Program management requires comprehensive information support, but current monitoring and evaluation of preventive services are inadequate. The established system of maternal and child health has distinct advantages. Gynecologists and obstetricians, providing preventive and curative reproductive health services for women, are directly accessible at the primary health care level. Health care services covering family planning counseling, contraceptive measures, pregnancy, and childbirth (and the cervical cancer screening program), are fully covered by compulsory health insurance. Although coverage of certain services (eg, mother and child programs, vaccinations) have been traditionally high, there is a need for research and

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Volume 177S improvement in low or late enrollments, specifically in lower socioeconomic groups and some ethnic groups.

Conclusions Slovenia tends to be in line with the goals for the development of pediatric health care at the primary level in European countries, which are to maintain the high level of quality, improve, and provide more equitable access and delivery of services, with the aim of reducing inequalities and provide for every child and adolescent in the best possible way. There is a threat that because of different levels of responsiveness or insufficient information, as well as unbalanced access to preventive services, inequalities in health will increase. Another threat is that the lack of human resources and increasing demands on curative health care for the elderly population could prevail. Slovenia is faced with the dilemma of whether to maintain and enhance the current preventive program in line with the proportionate universalism approach, or to focus on only at risk groups within the current health insurance scheme. Current efforts are aimed toward better provision of pediatricians by employing new specialists in pediatrics in primary health care and in regions with a lack of pediatricians. It is also important to ensure professional standards for establishing an accessible 24-hour pediatric service. n

Author Disclosures The authors declare no conflicts of interest. We thank all colleagues from the Slovenian Pediatric Society, the Pediatric Nurses Association and clinical psychologists who helped with discussions and contribution to the knowledge base of this article: Peter Najdenov MD, Vesna Plevnik Vodu
sek, MD, Ajda Cimperman, MD, Bernarda Vogrin, MD, Rok Kosem, MD, Majda Benedik Dolni
car, MD, Nata
sa Poto
cnik Daj
cman, MD, Tatjana Grmek Martinja
s, MD, Ema Jereb, MD, Nevenka Zavrl, MD, Andreja Borinc, MD, Natalija Krajnc, MD, Majda Troha, MD, Jana Kodric, Majda O
stir, Sandra
Coderl, and Bernarda Dobnik Renko. We also thank Dianne Jones for editing the text in US English.

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