Z majhnimi koraki do velikih sprememb

V prvi letošnji epizodi vladnega podkasta GOVSI ministrica za zdravje dr. Valentina Prevolnik Rupel predstavlja sveže potrjeno novelo zakona za prenovo zdravstvenega sistema. 

Osrednja tema so izboljšave, ki zagotavljajo boljšo dostopnost do zdravstvenih storitev, višjo kakovost obravnave za paciente ter stabilnost in finančno vzdržnost javnega zdravstva. Ministrica pojasnjuje, kako nova zakonodaja uvaja pravičnejše nagrajevanje zdravstvenega osebja, jasnejšo ureditev javne zdravstvene mreže in učinkovitejše upravljanje čakalnih vrst.

Voditeljica Petra Bezjak Cirman z gostjo razpravlja o prizadevanjih za večjo motivacijo zdravnikov, regulaciji dela v javnem in zasebnem sektorju ter o zagotavljanju dolgoročne kakovosti in varnosti v zdravstvenem sistemu. Nova epizoda ponuja poglobljen vpogled v spremembe, ki vplivajo na vse prebivalce Slovenije.

Vabljeni k poslušanju na vaši priljubljeni platformi in ogledu!

[ENGLISH VERSION]
Small Steps Lead to Big Changes

In the first episode of this year’s GovSI podcast, the Minister of Health, Dr. Valentina Prevolnik Rupel, discusses the recently approved amendment to the healthcare system reform act.

The main focus is on improvements ensuring better access to healthcare services, higher quality patient care, and the stability and financial sustainability of public healthcare. The Minister explains how the new legislation introduces fairer compensation for healthcare workers, clearer regulation of the public healthcare network, and more effective management of waiting times.

Host Petra Bezjak Cirman and her guest delve into efforts to enhance the motivation of doctors, regulate work in the public and private sectors, and ensure long-term quality and safety within the healthcare system. This new episode offers an in-depth look at reforms affecting all Slovenian citizens.

You are invited to watch and tune in on your favorite platform! 

Transcript

Vladni podkast GOVSI. 

Voditeljica Petra Bezjak Cirman: Spoštovane in spoštovani, dobrodošli že v sedemnajsti epizodi vladnega podkasta Govsi, prve v letu 2025. Naš podkast nastaja v produkciji Urada vlade za komuniciranje, z vami pa sem Petra Bezjak Cirman. Našo ekipo bo veselilo, če spremljate podkaste, kjerkoli jih poslušate ali gledate. Današnja tema je ključna za vse. Zdravje. Vlada je namreč potrdila eno ključnih novel zakona za prenovo zdravstvenega sistema. Vemo namreč, da si je ta koalicija zadala, da bo krepila javno zdravstvo. In kaj prinaša prenova zdravstvenega sistema? Kako bo vplivala na paciente? Na vsa vprašanja bo odgovorila ministrica za zdravje Valentina Prevolnik Rupel. 

Gostja dr. Valentina Prevolnik Rupel: Pozdravljeni! 

Voditeljica: Pozdravljeni! Najprej pa za začetek kako se pravilno naglasi vaš priimek, Prévolnik ali Prevólnik? 

dr. Prevolnik Rupel: Prévolnik. 

Voditeljica: Korošica, torej. 

dr. Prevolnik Rupel: Ja, prihajam s Koroške iz Mislinje. 

Voditeljica: Torej močnega karakterja. 

dr. Prevolnik Rupel: Pravijo tako, da smo Korošci močnega karakterja. 

Voditeljica: Prihajate iz predavateljskih vod, če tako rečeva, kako se prejšnje delo razlikuje od zdajšnjega. Ste pričakovali, kako bo na tem ministrskem mestu? 

dr. Prevolnik Rupel: V bistvu ne prihajam iz predavateljski vod, jaz prihajam iz raziskovalnih vod. Prej sem delala na Inštitutu za ekonomska raziskovanja, precej let, seveda pa sem vmes delala že na drugih delovnih mestih, tudi na Ministrstvu za zdravje, v sektorju za ekonomiko, tudi na Zavodu za zdravstveno zavarovanje. Imam izkušnje tudi bolnišnicah, se pravi pri izvajalcih, kjer sem bila v kar nekaj svetih zavodov kot članica sveta zavoda ali pa tudi kot predsednica. Tako da imam neko tako zgodovino, da lahko, da sem že spoznala sistem iz različnih zornih kotov, kar mi pomaga pri sedanjem delu v veliki meri. Seveda pa nisem pričakovala, da bo to mesto tako zahtevno, kot je. Vedela sem seveda, da bo, ampak vseeno je veliko bolj zahtevno in zahteva veliko več energije, dela, pogovorov, kot sem nekako si uspela predstavljati, preden sem prišla sem. 

Voditeljica: Ta vlada je obljubila, da bo krepila javno zdravstvo in da bo šla v spremembe. Ko ste nastopili mandata, ste rekli, da bomo šli v spremembe v zdravstvenem sistemu z majhnimi koraki. Kaj ste s tem mislili? 

dr. Prevolnik Rupel: S tem sem mislila na to, da je zdravstveni sistem izjemno kompleksen in velik sistem, ki ga je treba konstantno stalno prenavljati in skrbeti zanj. Se pravi, vedno je treba biti pozoren, spremljati, kaj se v sistemu dogaja, ga analizirati in sproti sprejemati neke ukrepe oziroma majhne korake, ki ga nekako utirijo in vodijo v smer, ki jo želimo. Naša smer je seveda jasna: zagotoviti dostopnost in ko enkrat ljudje lahko dostopajo do zdravstvenih storitev, da so te kakovostne. Vse seveda ob nekem stabilnem finančno vzdržnem zdravstvenem sistemu, tako da majhni koraki so potrebni na več področjih. Ker zdravstveni sistem je res velik. Če si samo predstavljate, od zdravil do preventivnih programov do vseh investicij do sekundarnega terciarnega zdravstva, tako da je cel spekter, za katerega je potrebno skrbeti. 

Voditeljica: Kar nekaj korakov ste že naredili. V javnosti morda niso bili tako odmevni. Kaj vse ste že naredili? 

dr. Prevolnik Rupel: Torej, naredili smo res že kar veliko. Delamo vzporedno na več področjih. Želimo seveda, da so vse spremembe čim bolj gladke, se pravi, da ne pretresajo zdravstvenega sistema. Če se le da. Je pa res, da so nekatera področja taka, kjer ukrepi zamujajo, kjer bi lahko bili sprejeti že kar precej let nazaj in je zato sedaj sprememba nekoliko bolj boleča. Zagotovo pa so vse spremembe, ki jih uvajamo oziroma za katere se odločimo, premišljene, predebatirane. O njih razpravljamo z vsemi deležniki, ki so v zdravstvu, od pacientov do zdravnikov in drugega zdravstvenega osebja, se pravi medicinskih sester in ostalih poklicev, kot seveda tudi na ekonomsko socialnem svetu. Se pravi delodajalci, sindikati, tako da vnos vsake spremembe terja kar nekaj časa. Vse spremembe so, kot sem rekla, usmerjene v povečanje dostopnosti in kakovosti. Recimo, zdaj ne bom mogla seveda našteti v tem kratkem času, ki ga imava na voljo, vseh, ampak na primer na primarnem zdravstvenem varstvu veste, da smo naredili veliko sprememb tudi z zadnjim zakonom o zdravstveni dejavnosti, kjer smo približali to raziskovalno dejavnost oziroma Klinični inštitut na primarni ravni. Sicer pa veste, da smo šli v lanskem letu v prenovo glavarinskih količnikov, se pravi v spremembo načina plačevanja primarne zdravstvene dejavnosti na način, da bodo zdravniki čimbolj pravično plačani oziroma da bodo bremena med njimi čimbolj enakomerna. Prav tako smo recimo motivirali oziroma preko finančnih mehanizmov spodbudili vsakega družinskega zdravnika, da opredeli čim več pacientov. Se pravi, da je recimo od tiste meje, ki je določena za odklanjanje, glavarinski količnik je vreden zdaj kar 140 odstotkov. Zato, da se zdravniki čim bolj odločajo za to, da opredelijo več pacientov. Take motivacije v sistemu so pomembne na vseh ravneh, tako da tudi na primarni ravni. In prav je, da tudi na primarni gremo v to smer. Še posebej, ker primar je tisti, kjer pacient prvič pride v stik z zdravnikom, Zelo pomembna sprememba je model spodbujanja motivacije prvih pregledov na specialistiki, se pravi na sekundarni ravni. Se pravi, gre za specialistično ambulantno dejavnost, kjer želimo, da imajo pacienti čim boljši, čim hitrejši dostop do prvega pregleda. Se pravi, da se iz čakalnih vrst premaknejo v zdravstveni sistem. V ta namen smo bolj stimulirali spet plačilo prvih pregledov, kjer smo plačilo povečali za 30 odstotkov in smo določili tudi neko absolutno minimalno število prvih pregledov po posameznih dejavnostih. Recimo kardiologija, ortopedija. Da, da smo spodbudili izvajalce, da izvedejo več prvih pregledov in s tem nekako potegnejo paciente, ki čakamo na čakalnih vrstah, k zdravniku. Torej sta samo dva, dva taka primera. 

Voditeljica: To je vprašanje, ko ti zboliš. Prva stvar je: želiš iti v zdravstveni dom? Vemo, da se je kar nekaj zdravnikov upokojilo in da kar nekaj ljudi zdaj nima izbranega zdravnika. Torej, na tej ravni ste urejali zadeve. To je prvo. 

dr. Prevolnik Rupel: Tako. 

Voditeljica: In potem drugo. Ko dobiš za specialista, pa verjetno čakaš v vrsti, da prideš na vrsto na sekundarni ravni. Kako je pa stanje zdaj? Pri čakalnih vrstah? So daljše, se krajšajo? 

dr. Prevolnik Rupel: Tako je. Mi smo se res osredotočili predvsem na dve stvari. Prvo je, kot sem omenila, prvi pregledi, kjer je število vseh čakajočih, kot tudi število nedopustno čakajočih, padlo. Recimo v teh trinajstih dejavnostih, ki smo jih posebej označili oziroma smo ta ukrep z boljšim plačevanjem prvih pregledov usmerili na njih, je recimo bilo število kar trikrat manjše, kot je bilo na začetku leta. To govorim o številu nedopustnih čakajočih. Res pa je, da smo vmes spremenili tudi definicijo, kaj je nedopustno čakajoči. Ta definicija prej ni bila jasna in je bilo tudi spremljanje nedopustno čakajočih ... Ni se vedelo, kdaj nekdo postane nedopustno čakajoč. To smo zdaj s pravilnikom o čakalnih seznamih prenovili definicijo, tako da je zdaj popolnoma jasno in je tudi bolj smiselna definicija. Je pa tako, da bil je vmes en tak velik padec takrat, ko je prišlo do spremembe pravilnika, ampak tudi kasneje. V kasnejših mesecih se je število vsak mesec nedopustno čakajočih nižalo in tudi število vseh čakajočih, kjer pa definicija ni bila spremenjena, pada. Tako da to je zagotovo nek tak uspeh, ker v bistvu pomeni ... Če pogledamo pretekla leta, je število čakajočih, vseh čakajočih, kot tudi število nedopustnih čakajočih skozi leta naraščalo. Zdaj pa ne samo, da narašča počasneje, pač pa je celo opazen negativen trend. Se pravi, da je začelo padati. To je zagotovo en tak uspeh. Seveda pa ta uspeh povečuje, ko nekdo pride v sistem na prvi pregled, po prvem pregledu potrebuje dodatne storitve. In ker smo jih več potegnili v sistem, se pravi po prvem pregledu, je seveda število čakajočih na nadaljnje korake povečalo. To je povsem pričakovano. To smo vedeli. Ampak vseeno se nam je zdelo, da je zelo pomembno, da pacient pride do prvega pregleda, do prve obravnave. Se pravi, da ne čakamo v čakalnih vrstah brez diagnoze in ne vemo, kaj nam je. Seveda pa potem, ko je prvi pregled, diagnoza postavljena, je veliko lažje, tudi paciente usmeriti naprej in povedati, kdo lahko čaka na nadaljnje obravnave, kdo pa ne. Tako da ja. 

Voditeljica: Marsikdo pravi, da ko enkrat prideš v zdravstveni sistem, imaš odlično obravnavo. Imamo odlične zdravnike, odlične programe Dora, Zora, Svit. Potem imamo zelo majhno število novorojenčkov. Torej, naš javni zdravstveni sistem je zelo dober. 

dr. Prevolnik Rupel: Jaz mislim, da je naš javni zdravstveni sistem izjemno dober, tudi strokovno, predvsem strokovno mamo izjemno dobre rezultate. Tudi bi rekla, da je stroškovna učinkovitost sistema izjemna s takšnim deležem sredstev, se pravi v bruto domačem proizvodu, kot ga mi namenjamo za zdravstvo, so naši kazalniki od pričakovane življenjske dobe od pričakovanih zdravih let življenja so izjemno dobri v primerjavi recimo tudi z Avstrijo, s katero se zelo radi primerjamo. Recimo Avstrijci imajo približno enako pričakovano življenjsko dobo in manj pričakovanih zdravih let življenja, vlagajo pa recimo tam okrog 11 % BDP za zdravstvo. Medtem ko naš procent je tam okrog 9,6 % ali 9,7 %, pa imamo boljše kazalnike. Tako da jaz bi rekla naš sistem se z vidika teh krovnih kazalnikov, ki so nam pomembni, kako dolgo bomo živeli, koliko zdravih let lahko nekdo pričakuje, je naš sistem izjemno dober. 

Voditeljica: Moram se dotakniti teme lanskega decembra. Ko je v Ameriki močno odmeval umor direktorja največje ameriške zdravstvene zavarovalnice. Ta kruti zločin je pozneje postal katalizator za vse, kar je narobe z ameriškim zdravstvenim sistemom, kjer umre do 55 tisoč ljudi na leto, ker nimajo zdravstvenega zavarovanja. Verjetno si v Sloveniji ne želimo takšnega sistema, kjer te ocenjujejo in zdravijo po tem, koliko plačaš za zdravstveno zavarovanje. 

dr. Prevolnik Rupel: No, zagotovo ne. Niti zgodovina Slovenije ni takšna niti vrednote naše niso takšne, da bi si želeli tak sistem. Kot veste, se mi trudimo res ves čas, da bi imeli univerzalno zavarovanje, se pravi zavarovanje za vse prebivalce Slovenije, za prebivalke in prebivalce Slovenije. In tudi dejansko smo vsi vključeni v zdravstveni sistem. Če rečemo, da kdo ni zavarovan, veste se, ta procent je ta delež manj kot procent in še to je zaradi prehodov med statusi. Recimo ko nek študent neha biti študent, pa si išče zaposlitev, je tisti vmesni čas se šteje, kot da je recimo nezavarovan, ko se ureja status, tako da večina izhaja iz tega, kar je nezavarovanih pri nas. Ker res imamo to pokritost zelo visoko in mislim, da smo vsi s tem zadovoljni kot narod, kot Slovenci, kot Slovenke si tega želimo in smo za to tudi pripravljeni plačati določene prispevke. V Ameriki je to seveda drugače. Izhajajo iz povsem drugačne premise, iz povsem drugačne zgodovine. Vedeti pa moramo, da je delež teh nezavarovanih ljudi, ki nimajo zavarovanja, okrog 10 %. Menda je v zadnjem času nekoliko padel, ampak se giba tam okrog 10 %, tako da zagotovo si mi tega res ne želimo. 

Voditeljica: In če greva zdaj na aktualno temo, novelo Zakona o zdravstveni dejavnosti. Ta naj bi poskrbela, da bo več zdravnikov delalo ravno v tem sistemu javnega zdravstva in ne toliko zasebnega. Kaj vse prinaša? 

dr. Prevolnik Rupel: Se pravi, novela Zakona o zdravstveni dejavnosti se predvsem osredotoča na urejanje zdravstvene dejavnosti. Če se vprašamo, kaj bo pacient, kaj bomo ljudje imeli od tega? Izvedeli bomo, da je sistem urejen. Kdaj, h komu lahko gremo in kdo lahko kje dela? Zakon o zdravstveni dejavnosti je v bistvu nekako uredil to, kar je mogoče šlo v našem sistemu predaleč. To je tisto, kar sem prej govorila, da so mogoče nekateri zakoni sprejeti nekoliko bolj pozno, kot bi lahko bili, saj je pri nekaterih dejavnosti recimo že toliko zdravnikov, šlo iz zdravstvene dejavnosti. Govorim recimo o radiologiji, da je že več kot polovica storitev opravljena izven javnega sektorja. To seveda zmanjšuje dostopnost ljudi do storitev v javnem zdravstvenem sistemu, zato je bilo ta korak potrebno narediti. Kar vidim kot zelo pomemben doprinos, je to, da zakon jasno definira, kaj je javna zdravstvena mreža. Se pravi, to so javni zdravstveni zavodi in koncesionarji in da definira razmerja, kako lahko zdravnik neko dejavnost opravlja. To, da se je prej lahko delalo preko s.p.-jev, d.o.o.-jev. Nekdo, ki je bil zaposlen v javni zdravstveni mreži in je popoldan delal pri zasebnikih izven javne zdravstvene mreže, govorimo o čistem, samoplačniškem delu, je lahko vodilo do tega preusmerjanja, prenaročanja pacientov. Poleg tega s.p. ni dejansko oblika, oblika zaposlitve, ki bi bila primerna za tako opravljanje dela. Vemo, da je treba upoštevati Zakon o gospodarskih družbah, ki točno definira, kdaj je s.p. tista oblika, po kateri se lahko delo opravlja. Tako da zakon tukaj postavlja neke meje, ureja, regulira zdravstveno dejavnost. 

Voditeljica: Veliko je takih primerov. Tudi, kdo je posnel takšen primer? Kličemo zdravnika v zasebno ambulanto, se nam javi. Plačamo, ampak vemo, da je v bolnišnici, ki je pa javna, do njega ne pridemo. Torej teh praks ne bo več. 

dr. Prevolnik Rupel: Teh praks ne bo. Dejstvo bo, da zdravniki bodo sedaj morali se odločiti, kje bodo počeli. Veste, tista mala izjema, ki jo imamo za neko varovanje javnih zavodov v primeru, da bodo potrebovali nekega strokovnjaka, ki je na trgu. Se pravi, govorimo o tem, da če bo prišlo po nekem povpraševanju po nekem vrhunskem strokovnjaku, ki ga bodo potrebovali v javnem zavodu, bo še vedno mogoča delna zaposlitev. 

Voditeljica: Ampak ta bo verjetno imel službo za nedoločen čas zasebno in bo pomagal javnemu zdravstvu. Zdaj je bilo pa ravno obratno. So imeli službo za nedoločen čas v javnem zdravstvu in so ... 

dr. Prevolnik Rupel: Lahko popoldne delali zasebno. Koncesionarji so všteti v javna dela. Koncesionarji so šteti v javno zdravstveno mrežo. 

Voditeljica: Kakšne spodbude pa prinaša zakon, zato, da bi zdravniki ostali v javnem zdravstvu? 

dr. Prevolnik Rupel: Spodbud je kar nekaj, a večinoma se v javnosti govori o teh davčno bolj ugodnih podjemnih pogodbah. Ampak meni se bolj pomembno zdi, da zakon jasno postavlja to merjenje efektivne obremenjenosti dela. Se pravi, da bomo končno enkrat spremljali in vedeli, kdo koliko naredi. In tisti, ki bo naredil več. Govorim o delu v rednem delovnem času. Bo lahko preko variabilnega nagrajevanja, kar so želeli zdravniki sami, zdravniki in drugi zdravstveni delavci. Da, tisti, ki bodo naredili več, bodo lahko za to več plačani. To je omogočil seveda ta novi zakon o skupnih temeljih za plače v javnem sektorju. Tako da jaz sem vesela tega dodatka. Tudi sem vesela, da je z zakonom o zdravstveni dejavnosti mogoče, da se to variabilno nagrajevanje začne prej, se pravi, da bo omogočil začetek pred tem že v letu 2025. To variabilno nagrajevanje je pomembno, daje pomembno orodje v roke poslovodstvu. Se pravi menedžerjem, da identificirajo, najdejo, izmerijo in nagradijo tiste, ki so recimo bolj pridni oziroma ki naredijo v rednem delovnem času več. Seveda, dodatno pa so potem še podjemne pogodbe za, recimo za delo izven rednega delovnega časa, ki pa nimajo tega plačila tega posebnega davka. 

Voditeljica: Tako bo lahko torej zdravnik iz javnega zavoda Bolnišnice Celje delal tudi v Zdravstvenem domu Celje. 

dr. Prevolnik Rupel: Lahko bo delal, v kolikor bo seveda imel za to soglasje, soglasje pa bo dobil pod določenimi pogoji. Ta pogoj je, da bo najprej seveda opravil delo v svojem matičnem zdravstvenem zavodu in to delo bo zdaj merjeno. Potrebno bo narediti redni program v sklopu Zavoda za zdravstveno zavarovanje in ko bodo ti pogoji izpolnjeni, bo lahko dobil, če ne bo potrebe, če ne bo odklanjal nadurnega dela. Pogoji so specificirani v zakonu. Bo lahko dobil soglasje direktorja, da opravlja delo drugje v okviru javne zdravstvene mreže, seveda. 

Voditeljica: Kdo pa bo pripravil ta merila? 

dr. Prevolnik Rupel: Merila so že specificirana v zakonu. Se pravi en člen, ki določa, kateri pogoji morajo biti izpolnjeni za izdajo soglasja. Efektivni delovni čas. Kako bo izgledal? Kdo bo to pripravil? Efektivno delovno obremenitev ... Metodologija za merjenje te bo enotna po celi Sloveniji. Pripravljamo jo na ministrstvu za zdravje, sicer pa bo to bolj služilo kot orodje vodstvu, da bodo imeli v rokah neko metodologijo, s katero bodo lahko to merili in jo potem tudi uporabljali za to, da bodo določili, kdo lahko dobi soglasja in kdo ne. 

Voditeljica: Večkrat ste že omenili vodstvo. Tudi za njih se spreminja, da bodo 100-odstotno posvečeni vodenju javnega zdravstvenega zavoda. 

dr. Prevolnik Rupel: Ja, zdaj v zakonu smo to določili za vse, razen za manjše zdravstvene zavode, se pravi, kjer že sam akt o ustanovitvi oziroma statut določata, da je lahko ta delež zaposlitve nižji, se pravi 60 %, kar je minimum. Na ministrstvu sicer zdaj še delamo analizo, kolikšen delež, za kolikšen delež so zaposleni direktorji teh javnih zdravstvenih zavodov. Ugotovili smo, da imamo tudi npr. zavod, kjer je direktor zaposlen za pet odstotkov. Takih praks ne bo. 

Voditeljica: Direktorji, ki so istočasno zdravniki, se bojijo tudi, da bi zaradi te določbe od stotih odstotkov izgubili licenco, kar pa ne drži. 

dr. Prevolnik Rupel: Seveda bo dopolnilno delo in delo po nadurah omogočeno tudi vnaprej, kar jim seveda omogoča ohranjanje licence. 

Voditeljica: Kako pa je z javno zdravstveno mrežo? Se na tem področju zdaj kaj izboljšuje? 

dr. Prevolnik Rupel: Se pravi, javno zdravstveno mrežo si na ministrstvu, veste, da želimo to mrežo zdravstvenih zavodov narediti v Sloveniji po moje že 20 let, pa nam do sedaj nekako ni uspelo. Ampak mreža itak je, mrežo imamo postavljeno. Seveda pa ne vemo, ali je optimalna ali so kje neke sive točke, kjer nekaj manjka, kjer pacienti nimajo dostopa do zdravstvenih storitev. Se pravi, posnetek javne zdravstvene mreže in njeno optimizacijo smo si kot cilj v ministrstvu zastavili za naslednje ... Za naslednje leto, ker jo želimo pripraviti v sodelovanju z deležniki, se pravi z Nacionalnim inštitutom za javno zdravje. Tudi Strateški svet za zdravstvo, Strateški svet vlade za zdravstvo se intenzivno vključuje v pripravo te mreže na vseh nivojih in po dejavnostih. Tako da to je naša naloga, zagotovo ena glavnih nalog za naslednje leto, da to mrežo bolj natančno definiramo. Pri tem bi rada povedala, da ko rečem mreža, ne mislim samo na posamezne izvajalce, pač pa mislim seveda na vse, kar mreža prinaša. Ne samo na lokacijo, pač pa na obseg storitev, na kakovost storitev, na kadre, na vse. To je mreža. Mreža je tako rekoč vse, kar imamo. Slabih pet milijard je vreden proračun zdravstvene zavarovalnice in pravijo, da toliko je tudi različnih interesov. 

Voditeljica: Pri zadnji noveli zakona se to zelo dobro vidi. Največji očitek je v bistvu ta, da bodo zdaj vsi zdravniki zbežali v zasebno zdravstvo in bo javna zdravstvena mreža še manj dostopna. Ali pričakujete kaj podobnega? 

dr. Prevolnik Rupel: No, to, da bodo vsi zdravniki zbežali, tega zagotovo ne. Saj tudi ni ... Če pogledate Slovenijo, mislim, tudi ni takega ogromnega zasebnega trga, da bi se to lahko zgodilo. Poleg tega vemo, da so koncesionarji v okviru javne zdravstvene mreže. Kot sem že rekla, zagotovo pa bo kateri od zdravnikov verjetno sprejel odločitev in se odločil, da bo šel na zasebni trg. To so predvsem nekatere dejavnosti, kjer je to mogoče, kjer je zasebni trg dobro razvit, recimo maksilofacialna kirurgija ali dermatologija, kjer je že sedaj zasebni trg velik. Tako da, ja, zagotovo bo kdo šel. Seveda pa se mi vseeno zdi prav, da tako kot na vseh drugih področjih, tudi na področju zdravstva vemo, da mora veljati neka konkurenčna prepoved in da zadevo, zakon o zdravstveni dejavnosti predvsem ureja, kaj se lahko, kaj pa ni primerno. In da se upošteva druge zakone z drugih področij, ki določajo to konkurenčno prepoved. In pa recimo oblike dela, ki so možne v zdravstvu. 

Voditeljica: Zdaj si moramo naliti čistega vina. 

dr. Prevolnik Rupel: Tako, da. Zasebniki, če tako pogledava, vzamejo profitabilne zadeve, medtem ko se težje operacije vedno selijo v javno zdravstvo, so tudi dražje in zato je tako pomembna ta javna zdravstvena mreža. 

Voditeljica: Bolnišnice, ki opravljajo najtežje operacije, ki jih zasebniki ne. Verjetno moramo to povedati naglas. 

dr. Prevolnik Rupel: Glejte, to je namen celega sistema, da se selijo. Namen bolnišnic je, tako univerzitetnih kliničnih centrov kot splošnih bolnišnic, da vzamejo te težje primere. Naša osnova javnega zdravstvenega sistema so javni zdravstveni zavodi. Koncesionarji so kot dopolnilo. To je bilo ves čas tako mišljeno. Koncesionarji so kot dopolnilo javnih zdravstvenih zavodov, česar javni zdravstveni zavod ne more, tista dejavnost ... Nekdo jo mora opraviti. Tudi te lažje operacije oziroma nekaj operacij, ki jih je možno opraviti izven javnega zdravstvenega zavoda in tudi pogoji ni nujno, da so enaki za te operacije, ki so rečemo elektivne ali prospektivni program, ki jih je lahko planirati. Se pravi in je prav, da s tem niti ne obremenjujemo bolnišnic. Mogoče je prav, da take posege, ki vemo po celem svetu, po celi Evropi vemo, katere to so, da se izločijo iz javnih bolnišnic. Tako da to, da se selijo zahtevne tja, prav je tako. Bolnišnica mora imeti neko drugo vlogo, kot pa jo ima koncesionar. 

Voditeljica: Zasebnike mislim v luči plastičnih posegov in podobno. 

dr. Prevolnik Rupel: Ja, to je pa čisti zasebni trg, kjer pa zagotovo so tiste operacije, ki so ... Zasebno zdravstvo ima seveda drugačen cilj, kot ga ima javno. Profit, ja. To so take dejavnosti, ki seveda se lahko izvajajo na trgu in tržna dejavnost je tudi dejavnost, ki živi v zdravstvu v celi Evropi. In Slovenija ni nobena izjema. Čisti zasebni trg je in bo in se bo tudi razvijal. Naš namen je samo, da to ustrezno reguliramo in uredimo. 

Voditeljica: Omenili ste koncesije. Tudi tukaj se je skozi leta nabralo nekaj izzivov. Se bodo še vedno lahko dedovale? Se tukaj kaj spreminja? 

dr. Prevolnik Rupel: Tudi pri koncesijah se spreminja. Ta zakon prinaša to, da je koncesija vezana na dejanskega lastnika. Se pravi, da se koncesija v primeru spremembe lastništva odvzame oziroma prodaja ni več mogoča v smislu kopičenja koncesij. Se pravi, v kolikor pride do prodaje koncesije, je ta pogodba nična. 

Voditeljica: Pomanjkanje zdravstvenih delavcev? Kakšne ukrepe ste pa na tem področju sprejeli na ministrstvu? Celo zdaj se pričakujejo spet neki spremenjeni pogoji, če prav razumem, za poklicne kvalifikacije. Veliko zdravstvenih delavcev že zdaj pripeljemo iz tujine. Kako je s področjem jezika? 

dr. Prevolnik Rupel: Se pravi, tudi na tem področju smo seveda sprejeli določene ukrepe. Je pa res, da kadar govorimo o ljudeh, kadar govorimo o kadrih, ti ukrepi morajo biti dolgoročni, kar velikokrat očitajo. A dejstvo je, da če imamo omejeno število zdravnikov, zelo težko v enem tednu, v enem mesecu pripeljemo nove zdravnike, nove medicinske sestre oz. tudi drugo zdravstveno osebje, zato so naši ukrepi na tem področju dolgoročni. Vseeno pa je pomembno, da jih vlada sprejme, četudi učinka ne bo danes, ampak zagotovo se bo pa poznalo na dolgi rok, kar lahko v tem trenutku naredimo in tudi smo, je zakon o poklicnih kvalifikacijah, kjer smo olajšali in skrajšali postopke prihoda tujega zdravstvenega kadra, se pravi kadra iz tujine. Kar nekaj jih imamo, ki čakajo na to, da lahko začnejo delati pri nas, od družinskih zdravnikov, zobozdravnikov In prav je, da seveda ob ustreznem preverjanju, ob ustreznem izpolnjevanju pogojev, da jim te postopke čim bolj skrajšamo. Ukrepi gredo v to smer, da je ministrstvo za zdravje ena točka, iz katere se vodi celoten postopek. Prej je to bilo tako, da je moral kandidat tekati na več točk, zbirati potrdila, zdaj pa pride na ministrstvo za zdravje, kjer se postopek centralno vodi in je zato tudi hitrejši, cenejši in lažji za kandidata. To se mi zdi kar pomemben ukrep, poleg tega pa seveda želimo pritegniti čim več zdravstvenih kadrov z ustrezno motivacijo na tista področja, kjer je pomanjkanje največje, na primer pomanjkanje družinskih zdravnikov. Veste, da smo z interventnim zakonom podaljšali možnost štipendij, v kolikor se nekdo odloči. Okrepili smo tudi tim zato, da olajšamo delo znotraj tima z 0,5 diplomirane medicinske sestre. Ja, številne male ukrepe, ki motivirajo mlade, da se odločajo za te poklice. 

Voditeljica: Že prej sem omenila upokojevanje zdravnikov torej družinske medicine. Uvedli smo že pred časom ambulante za neopredeljene, zdaj so se preimenovale. To je v bistvu zelo dober ukrep. Vsak, ki izgubi zdravnika, gre lahko v to ambulanto in ga ima. Ali se ljudje sploh zavedajo tega? 

dr. Prevolnik Rupel: Ja, res je, te ambulante smo preimenovali v dodatne ambulante. Kot sem že rekla, razlika med družinskimi ambulantami, se pravi, recimo rednimi ambulantami, in dodatnimi ambulantami je predvsem v načinu dela. Se pravi, v rednih ambulantah ima vsak pacient svojega izbranega osebnega zdravnika, medtem ko je v dodatnih ambulantah opredelitev na ambulanto. Se pravi več zdravnikov dela v tej ambulanti ravno zato, ker zdravnikov ni dovolj. Mi si seveda želimo, da bi bili vsi lahko opredeljeni na zdravnika, se pravi v teh rednih ambulantah. Ampak v teh razmerah se je pravzaprav ta ukrep izkazal za zelo pozitivnega. Saj važno je na koncu to, da vsak lahko pride do zdravstvene obravnave. Vsekakor pa si seveda na nek malo daljši rok želimo, da bi vsak imel izbranega osebnega zdravnika. To se mi zdi zelo pomembno, ker ko imaš svojega zdravnika in se z njim spoznaš, se mi zdi, da je veliko teh faktorjev, kot so recimo okolje, iz katerega izhaja, poznavanje družine, poznavanje zgodovine družine in bolezni, ki lahko dajo družinskemu zdravniku nek bolj celovit vpogled v pacienta. V kolikor pa pacient menjava zdravnike, pa tega stika vseeno ni, ki lahko sigurno da zdravniku tudi neko dodatno informacijo in spremeni obravnavo. Tako da na dolgi rok si prizadevamo za opredelitev na zdravnika. 

Voditeljica: Jaz se strinjam z vami, ampak moja izkušnja z dodatno ambulanto je izjemna. Same pohvale. Odzivna. Vendar si ne predstavljam, da bi ostala brez. 

dr. Prevolnik Rupel: Ne. Absolutno pravim, da je to zelo dober ukrep v vmesnem obdobju, da imamo vsi dostop do zdravstvene oskrbe. Zagotovo. 

Voditeljica: Odličen ukrep, ki se ga v primerjavi z ameriškim sistemom premalo zavedamo. 

dr. Prevolnik Rupel: Ja, ja, se strinjam. Primarna zdravstvena raven je pri nas res izjemna. Veste, da je tudi ... Ne samo v Evropi, pač pa tudi na celem svetu, je vedno izpostavljena kot primer dobre prakse. Po angleško se reče 'gatekeeper'. Da mi zaustavimo in veliko bolezni, obravnavamo na primarnem nivoju in rešimo že velik delež obravnav tukaj. To je večkrat izpostavila tudi Svetovna zdravstvena organizacija. Kako dobro imamo to organizacijo zdravstvene oskrbe na primarni ravni. Nič še nisva rekli o kakovosti. 

Voditeljica: V preteklosti ste se s tem veliko ukvarjali. Kako pa je na tem področju, kakovost v zdravstvu? 

dr. Prevolnik Rupel: Ja, zelo sem vesela, da smo sprejeli tudi zakon o zagotavljanju kakovosti v zdravstvu. Seveda, zakon je zelo pomemben z vidika varnosti zdravstvene obravnave in zagotavljanja kakovosti. Pri varnosti smo končno tudi zakonsko definirali vse pojme, se pravi od varnostnega incidenta do neželenih dogodkov in tako naprej. Definirali smo tudi celoten postopek, kako postopati, ko do nekega varnostnega incidenta, kateregakoli že, pride. To je zelo pomembno. Mogoče se premalo zavedamo, kako res zelo pomembno to je, saj če se recimo nekaj zgodi in se o tem pravilno poroča, se lahko to v naslednjem primeru prepreči. Ker samo, če bomo res sporočali varnostne incidente, preprečljive, škodljive dogodke, potem bomo lahko sprejeli ukrepe, jih predstavili kot dobre prakse in s tem preprečili, da se te napake v zdravstvenem sistemu ponavljajo. Napake v procesih, napake v obravnavi. In to je izjemnega pomena za varnost pacienta, za zdravje, za zdravstveno obravnavo. Na drugi strani zakon prinaša tudi recimo merjenje kakovosti. Kakovost definira kazalnike izidov. Recimo, veste, da zdravstveni sistemi so večinoma še vedno orientirani na vložke v sistem. Se pravi na 'inpute', potem na procese. Sedaj pa smo s tem zakonom res naredili tak velik preskok, ko smo se osredotočili tudi na izide, in sicer na tiste izide, ki so pomembni za pacienta. Če si predstavljamo, da bomo bolj plastični, recimo rak prostate, ena taka obravnava, sedaj merimo, vse, kar vemo o izidu, je samo, ali je pacient preživel ali ne. Kazalniki izidov, recimo v tem primeru, ki so zelo pomembni, pa so na primer tudi inkontinenca po določenem obdobju, ki je za pacienta pomembna. Njemu je po operaciji, recimo prostate, pomembno, ali je inkontinenten ali ni šest mesecev kasneje. In take kazalnike, če jih postavimo in spremljamo med izvajalci in ugotovimo, da je nekdo veliko boljši kot drug, lahko primerjamo procese in izboljšamo procese pri tistem, ki je slabši. Vse to vodi v boljšo in bolj kakovostno obravnavo, boljše zdravljenje, boljše izide za vsakega od nas. Tako da ti kazalniki kakovosti so zagotovo nekaj, kar zakon prinaša in je pomembno predvsem za paciente. 

Voditeljica: Še dobro leto je do konca vašega mandata. Imate kakšen poseben cilj, ki bi ga želeli doseči? 

dr. Prevolnik Rupel: Ja, zagotovo. Ko smo že ravno pri kakovosti, moramo sedaj ta zakon spraviti v življenje. Se pravi, potrebnih je nekaj podzakonskih aktov, potrebno je postaviti agencijo. Na ministrstvu pripravljamo tudi že te kazalnike kakovosti, o katerih sva govorili, tako da bodo čim hitreje lahko zaživeli v praksi. Pripravljamo tudi že, imamo skupino za klinične smernice, kjer smo naredili protokol, kako se bodo klinične smernice pripravljale. Veste, da tudi na tem področju se trudimo že kar nekaj let, pa kliničnih smernic nimamo dovolj oz. niso vsa klinična področja pokrita s smernicami, tako da to je zagotovo eno področje. Drugo področje, ki ga bomo urejali v tem letu, je zagotovo mreža, se pravi zdravstvena mreža. 

Voditeljica: To je zelo velik, zahteven projekt. 

dr. Prevolnik Rupel: Ja, pa zagotovo imamo še veliko ciljev. Potrebno je uskladiti koncesijske pogodbe. Na tem področju bomo morali tudi zagristi. Ja, kar veliko dela nas še čaka za eno leto. 

Voditeljica: Bo čim bolj uspešno in seveda zdravo. 

dr. Prevolnik Rupel: Ja, hvala lepa. 

Voditeljica: Hvala, da ste bili naša gostja. Vsem gledalcem in gledalkam, poslušalkam in poslušalcem pa želimo uspešno leto 2025.

[ENGLISH VERSION]
GOVSI Government Podcast

Host Petra Bezjak Cirman: Greetings. Welcome to the 17th episode of the GOVSI podcast, the first of 2025. Our podcast is produced by the Government Communication Office. My name is Petra Bezjak Cirman. Our team will be happy if you follow our podcast on any platform of your choosing. Today's topic, healthcare, concerns everyone. The government has approved a key amendment to reform the healthcare system. This coalition has committed to strengthening public healthcare. What does the healthcare reform entail? How will it impact patients? All questions will be answered by the Minister of Health, Valentina Prevolnik Rupel. Greetings.

Minister of Health Valentina Prevolnik Rupel: Greetings.

Host: First, how is your last name pronounced? Prévolnik or Prevólnik?

Prevolnik Rupel: Prévolnik.

Host: A Carinthian, then?

Prevolnik Rupel: Yes, I'm from Mislinja.

Host: And strong of character.

Prevolnik Rupel: Yes, they say Carinthians are strong of character.

Host: You were a lecturer before. How does your previous work differ from your current work? What did you expect from this position?

Prevolnik Rupel: I was actually not a lecturer, I was a researcher. I worked at the Institute for Economic Research for many years. I also worked in various other positions, including at the Ministry of Health in the Economics Sector, at the Health Insurance Institute, and I have experience in hospitals, meaning with service providers. I served on several institutional boards, either as a member or as chairwoman. This background allowed me to get to know the field from different perspectives, which helps me greatly in my current role. But I did not anticipate that this position would be as demanding as it is. I knew it would be, but still, it is significantly more demanding and requires much more energy, effort, and discussions than I initially imagined before taking on this role.

Host: This government promised change and stronger public healthcare. When you took office, you said we would change the healthcare system in small steps. What did you mean by this?

Prevolnik Rupel: I meant that the healthcare system is an incredibly complex and large system that requires constant updating and maintenance. We need to constantly monitor and analyse the system and continuously adopt measures or rather small steps that steer it in the direction we want it to go. Our direction is clear, to ensure accessibility, and provide quality healthcare services for people to access, while maintaining a stable, financially sustainable healthcare system. So, small steps are needed in various areas, as the healthcare system is very large, ranging from medicines to prevention programmes, investments, secondary and tertiary healthcare ... There is a whole spectrum that we must work on.

Host: You've already taken several steps that may not have garnered much public attention. What have you accomplished so far?

Prevolnik Rupel: We have done quite a lot. We are working simultaneously in several areas. Of course, we want all changes to be as smooth as possible so as not to shake up the healthcare system, if possible. However, there are areas where measures are late and could have been adopted years ago, which makes change a little more painful now. But all of the changes that we are implementing or opting for have been thought out and discussed. We discuss them with all of the stakeholders in healthcare, patients, doctors and other medical staff, meaning nurses and other professions, as well as the Economic and Social Council, meaning employers, unions ... So, implementing each change takes a long time. Like I said, all changes are aimed at increasing accessibility and quality. I cannot list them all in the short time we have here, but, for instance, we have made many changes in primary care, including amendments to the Health Services Act, where we brought research activities and the Clinical Institute closer to the primary level. As you know, last year we reformed the capitation coefficients, meaning we adjusted the payment model for primary healthcare to ensure fairer compensation for doctors and a more even distribution of workloads among them. Additionally, we introduced financial incentives to encourage family doctors to register as many patients as possible. For example, beyond the set threshold for refusing new patients, the capitation coefficient is now valued at 140%, motivating doctors to accept more patients. Such incentives are essential at all levels of the system, particularly in primary care, as it represents the first point of contact between the patient and the doctor. One key change is the introduction of a new model to promote first specialist examinations at the secondary level. This pertains to specialist outpatient services, where our goal is to ensure patients have better and faster access to their first examination and are moved out of waiting lists and into the healthcare system. To achieve this, we increased payments for first examinations by 30% and established a mandatory minimum number of first examinations for each specialty, like cardiology and orthopedics. This encourages providers to perform more first examinations and bring waiting patients into contact with a doctor. These are just two examples.

Host: When you fall ill, you first want to go to a health center. We know that many doctors have retired, leaving a large number of people without a chosen physician. You have been addressing issues at this level, correct?

Prevolnik Rupel: Yes.

Host: Secondly, once a specialist is assigned, patients face waiting lists to access secondary care. Are waiting times now getting longer or shorter?

Prevolnik Rupel: We mainly focused on two things. The first are first examinations, where the number of all waiting and inadmissibly waiting patients has decreased. In the 13 activities that we specifically targeted with this measure of better payment for first examinations, the number of inadmissibly waiting patients is three times lower than it was at the start of the year. It is true that we also changed the definition of inadmissibly waiting patients. The definition was lacking before, as it was not clear when someone becomes an inadmissibly waiting patient. We have now revised the definition with the regulations on waiting lines, so the definition is now perfectly clear and sensible. There was a significant reduction when the regulations were changed, but even later on, the number of inadmissibly waiting patients decreased every month. The number of all waiting patients, where the definition remains unchanged, is also dropping. If we look at previous years, the number of all waiting patients and inadmissibly waiting patients has increased over the years. Now it is not only increasing more slowly, we also see a negative trend, so, the number is dropping, which is a success. When someone enters the system for their first examination, afterwards, they need additional services. And because we have drawn more of them into the system, the number of people waiting for further services has increased. This was to be expected, but we thought it was important that patients get the first check-up, so that they get the diagnosis and know what is wrong. When we have the diagnosis, it is much easier to send patients to other doctors and know who can wait for further treatment and who cannot.

Host: A lot of people say once you are in the system, you get an excellent treatment. We have great doctors and programmes, such as DORA, ZORA and Svit. We have a very low newborn mortality rate. Our public healthcare system is good.

Prevolnik Rupel: I think it is excellent. We have great specialists and the system is very cost-efficient. With the percentage of GDP we allocate towards healthcare, our data, from life expectancy to our healthy years, are really good compared to Austria as well, which we like to compare to. Austrians have the same life expectancy, but less healthy years. They give 11% of their GDP for healthcare, while we give around 9.6, 9.7% and we have better data. I would say that based on the main data that are important to all of us, how long we will live, how long we will be healthy, our system is extraordinary.

Host: I have to talk about last December when the CEO of America's biggest insurance company was killed. This crime showed everything that is wrong with their system. Up to 55,000 people a year die there because they do not have an insurance. We do not want a system where you are treated according to how much you pay.

Prevolnik Rupel: Of course not. Our history and our values are different and we do not want a system like that. We are trying to have a universal insurance for everyone in Slovenia. We are all included in the healthcare system. Less than 1% of our citizens do not have an insurance and that is because of a status change, when a student is not a student anymore and is looking for a job and in the meantime, they do not have an insurance when the status is being changed. These are people without insurance. We really have a high coverage and we are happy with this, we want it as a nation, as Slovenians, and are also willing to pay for it. In America, they have a different premise and history. There, 10% of the population does not have an insurance. The number fell a little, but it is around 10% and we surely do not want this.

Host: Let's talk about the Health Services Act. It is supposed to insure that more doctors will work in the public system and not in the private sector. What will change?

Prevolnik Rupel: The amendment to the Health Services Act is focused on regulating health services. What will it bring to patients? We will know the system is organized, who we can go to and who can work where. The Health Services Act fixed what went too far in our system. As I said, some acts are passed later than they should be. In some areas, so many doctors left, in radiology, for example, that more than 50% of services are being provided outside the public system. This means services in the public system are less available and we had to make this step. It is very important that the Act defines the public system very clearly, we are talking about public institutions and concessionaires, and it defines how a doctor can work. Before, they worked as self-employed individuals in the private sector, although they were employed in a public institution. We are talking about complete self-paid services and patients had to make an appointment there. Besides, being self-employed is not suitable for this kind of work. We have to abide by the Companies Act that defines when you can do this kind of work. We set the boundaries and regulated health services.

Host: There are a lot of cases when we call a doctor in a private office, they answer, we pay, but we know that we cannot reach them in a public hospital. This will not be happening anymore?

Prevolnik Rupel: No. Doctors will have to decide where they will work. The exception we have is meant to protect public institutions if they will need a specialist. If there will be a demand for a top specialist in a public institution, they will be able to employ them.

Host: They will work at a private institution and will help a public institution. Before, it was vice versa. They were working in the public system ...

Prevolnik Rupel: And were able to work privately in the afternoon.

Host: Concessionaires are a part of the public system?

Prevolnik Rupel: Yes.

Host: How will you motivate doctors to stay in the public sector?

Prevolnik Rupel: There are several incentives. In the public, we mostly hear about contracts that will be taxed less, but to me, it is more important we defined measuring the workload, so that we will know who does how much. Whoever will do more, I am talking about regular work, will be rewarded which doctors and other healthcare workers wanted. Whoever does more, will be paid more. This was made possible with the new pay system in the public sector. I am glad this happened and that the Act makes it possible to start with this sooner, already in 2025. Rewards are important. They are an important tool for the management to identify and reward those who do more during regular work hours. Then we have contracts for work outside of regular hours which will be less taxed.

Host: So a doctor from Celje hospital will be able to work at the healthcare centre?

Prevolnik Rupel: Yes, if they will get a consent for it which they can get under certain conditions. First, they have to finish work at their primary institution, which will be measured. They will have to carry through the programme defined by the Health Insurance Institute and if they will not decline to work overtime, they will be able to work elsewhere in the public sector.

Host: Who will define criteria?

Prevolnik Rupel: They are defined in the Act. There is an article that defines which conditions must be met for the approval to be granted.

Host: What will effective working hours look like? Who will prepare this?

Prevolnik Rupel: The methodology for measuring it will be uniform throughout Slovenia. It's being prepared by the Ministry of Health, but otherwise it will serve more as a tool for the management to have a methodology in their hands, which they will be able to measure this with, and then use it to determine who can get approval and who can't.

Host: You've mentioned management several times, it's changing for them too. They will be 100% dedicated to the management of a public health institution.

Prevolnik Rupel: Yes. In the Act, we've made it a requirement for all except for smaller health institutions, where the statute stipulates that this proportion of employment can be lower, 60%, which is the minimum. The Ministry is currently doing an analysis of what percentage the directors of these public health institutions are employed for. We've found that we even have an institution where the director is employed for 5%. This will no longer be possible. The directors who are also doctors are afraid that they will lose their licence because of this provision of 100%, which is not true. Supplementary and overtime work will continue to be allowed, which of course allows them to keep their licence.

Host: What about the public health network? Are there any improvements in this area?

Prevolnik Rupel: The public health network ... We've been trying to form a network of health institutions in Slovenia for twenty years, but we haven't succeeded so far. But the network is there. We have the network, but we don't know if it's optimal or if there are some grey spots where patients don't have access to health services. A snapshot of the public health network and its optimisation is the Ministry's goal for next year. We would like to prepare it in cooperation with the stakeholders, the National Institute of Public Health, and the Government's Strategic Council for Health, which is involved in the preparation of this network at all levels. So that's certainly one of the main tasks for next year, to define this network more precisely. When I say network, I don't just mean individual providers, but everything that the network brings. Not just the location, but the range and quality of services, the human resources, everything. This is the network. The network is virtually everything that there is.

Host: The health insurance budget is €5 billion, and they say that there are as many different interests. The latest amendment shows this very clearly. The biggest criticism is that all the doctors are going to flee to private practices, and the public health network will be even less accessible. What are you expecting?

Prevolnik Rupel: I'm sure that's not true, because in Slovenia, there's not such a huge private market that that could happen. Besides, the concessionaires are within the public health network. But as I said, some of the doctors will probably decide to work in a private practice. Especially in some activities where that's possible, where private practices are well-developed. For example maxillofacial surgery or dermatology, where there is already a large private market. Some of them will certainly do that, but it still seems right to me that, as in all other fields, there must be a non-compete in the field of medicine. As I said before, the Health Services Act mainly regulates what can and can't be done. Other acts in other areas are taken into account, which provide for a non-compete, and, as I said, the forms of work that are possible in healthcare.

Host: We need to be honest.

Prevolnik Rupel: Exactly.

Host: The private practices take on profitable patients, while serious operations are always part of the public healthcare, and are more expensive. That's why the public health network is so important. Hospitals take on the most difficult cases that private practices don't. We need to say that out loud.

Prevolnik Rupel: That's the purpose of the whole system. That patients can be moved. The purpose of hospitals, both of university medical centres as well as general hospitals, to take the more difficult cases. The basis of the public health system are public health institutions, concessionaires are a complement, that's how it was always meant to be. Concessionaires are a complement to public health institutions. When a public health institution can't do something, somebody has to do it, even easier operations. Operations that can be done outside of the public health institution, and even the conditions are not necessarily the same. These are elective or prospective programmes that are easy to plan. It's right not to burden the hospitals with this, maybe it's right that certain procedures, Europe and the whole world know what they are, aren't performed in public hospitals. The hospitals should take on the serious operations. A hospital has to have a different role than a concessionaire.

Host: By private practices, I meant plastic surgery and the like.

Prevolnik Rupel: That's purely on the private market, where the operations ... Private healthcare has a different objective than public, profit. Certain activities can be carried out on the market. Profitable activities are part of healthcare throughout Europe, Slovenia is no exception. The purely private market exists and will continue to develop. Our intention is just to regulate it properly.

Host: You've mentioned concessions, where some challenges have accumulated over the years. Will they still be inherited?

Prevolnik Rupel: Concessions are also subject to change. The Act stipulates that the concession is linked to the actual owner. In the event of a change of ownership, the concession is withdrawn or the sale is no longer possible in terms of the accumulation of concessions. If there is a sale of the concession, the contract is null and void.

Host: There's a shortage of healthcare workers. What measures has the Ministry taken in this area? Revised conditions for professional qualifications are expected, we employ a lot of foreign healthcare workers. What's the situation with language?

Prevolnik Rupel: We have taken certain measures in this area as well. But it's true that, when we're talking about human resources, they have to be long-term, which is what is often complained about, but if we have a limited number of doctors, it's very difficult to bring in new doctors, new nurses, or other medical personnel in one week or one month. So our measures in this area are long-term, but it's important that the Government adopts them, even if the impact is not today, but it will certainly be felt in the long term. What we can do at the moment, and what we have done, is the Professional Qualifications Act where we have made it easier and shorter for foreign medical personnel, personnel from abroad. We have quite a few of them waiting to start working here, from family doctors to dentists, and it's right, of course, with the appropriate checks, with the right conditions being met, to shorten these processes as much as possible. The measures are going in the direction of the whole process being run by the Ministry of Health. Previously, the candidate had to run around and collect certificates, but now they come to the Ministry of Health, where the process is centrally managed and therefore faster, cheaper and easier for the candidate. I find this an important measure and of course, with a proper motivation we want to attract more personnel to the sectors with the biggest shortage. Family doctors, for example. With the Intervention Act we extended the chances for a scholarship. We have reinforced the team with a 0.5 registered nurse to facilitate the work in the team. There are a lot of small measures that motivate young people to choose these professions.

Host: I have mentioned before that family doctors are retiring. We've had the outpatient clinics that have a different name now. This is a good measure. Anybody that is without a doctor can go there and receive treatment. Are people aware of this?

Prevolnik Rupel: Yes, we've renamed these clinics to additional clinics. The difference between family clinics or regular clinics and these additional clinics is mainly in the way of working. In regular clinics every patient has a personal physician. In additional clinics you determine the clinic. More doctors are working there, because of the shortage. We wish that everybody could choose their doctor in the regular clinic, but in given situation this measure proved itself as a very good one. The most important thing is that everybody can get medical treatment. We wish that someday everybody would have a personal physician. I find it very important, because when you get to know your physician, there are a lot of factors, like the environment, where the patient comes from, knowing the family, knowing the history and the diseases. This can give a family doctor more wholesome view of the patient. If the patient is swapping doctors they are missing the contact that gives a doctor an additional information and changes the treatment. In the long term we try to get personal physicians.

Host: I agree with you, although I have a good experience with the additional clinic. Very commendable.

Prevolnik Rupel: Great.

Host: They are very responsive. But I can't imagine to be without.

Prevolnik Rupel: As I say, it's a good measure during the interim period to provide a medical treatment for everybody. Absolutely.

Host: It's a great measure. We are insufficiently aware of it in comparison with the USA's system.

Prevolnik Rupel: Yes. I agree with you. Our primary healthcare level is exceptional. Not only in Europe, but in the whole world, it is emphasised as an example of good practice. I would use the term gatekeeper. We stop and treat many illnesses on a primary level, where we solve a big part of treatments. Many times even the World Health Organization has emphasised how well we are organized on a primary healthcare level.

Host: We haven't talked about quality yet. You have addressed it in the past. What quality is our healthcare?

Prevolnik Rupel: I'm very happy that we have adopted the Act of providing the quality in our healthcare. The Act is very important as far as the safety of the treatment goes and ensuring the quality. We have finally defined all the terms of safety. From a safety incident to unwanted events and so on. We defined the whole procedure, too. What to do, if some kind of incident happens. I think it's very important. Maybe we are not aware, how very important this is. If something happens and it is being properly reported, it can be avoided next time. Only if we report the safety incidents, we can adopt the measures and prevent further mistakes in the healthcare from repeating. Procedural errors and treatment errors. This is extremely important for the patient's safety and good treatment. On the other hand, this Act includes the quality measurements. It defines the outcome indicators. The healthcare systems are still input oriented. This means inputs, processes. With this Act we have made a giant leap, when we focused on outcomes as well. On the outcomes, important for the patient. Let's try to imagine it. Prostate cancer, for example. Now we measure only, whether the patient survived. The other important indicator is incontinence after a certain period. It is important for the patient. After the operation the patient finds it important, whether he is incontinent six months later. If we monitor such indicators among doctors and find out that someone is better, we can compare the procedures and worse doctors can improve the procedures. It all leads to a better treatment and better outcomes for all of us. These quality indicators are something beneficial in the Act and they are important, especially for the patients.

Host: You have about one year to the end of your tenure. Do you have some special objectives?

Prevolnik Rupel: Yes, for sure. If we talk about quality, we have to put this Act into effect. We need a few bylaws and we need to establish the agency. At the Ministry, we are preparing these quality indicators, so they can be quickly put into practice. We have a group for clinical guidelines. We made a protocol, how to prepare these guidelines. We are trying to establish this quite a few years, but we don't have enough guidelines or all clinical areas aren't addressed. This is one area and the other area we plan to regulate this year is absolutely the network. The health network is a very demanding project. We still have a lot of objectives. We have to harmonise the concession contracts. We will have to bite in this area too. Yes, we have a lot of work for one year.

Host: I wish you a lot of success and health, of course.

Prevolnik Rupel: Thank you.

Host: Thank you for coming here. We wish a successful 2025 to our audience.