Urbani izziv, thematic issue, 2015, no. 1 65Interview Naja MAROT Mojca Gobec, director general of the Public Health Directorate on the relation between health policy and spatial planning: “What’s the point of being able to get to your doctor in five minutes if you have to wait fifteen months for a check-up?” This interview was carried out with Mojca Gobec, the direc- tor general of the Public Health Directorate at the Ministry of Health, which is in charge of preparing and implementing public health policies in Slovenia. Their policy is based on the principle of providing “health for everyone” and “health to all the policies”. − Policy preparation requires cooperating with many stakeholders. Who do you cooperate with in your every- day work? “The directorate works closely together with various minis- tries, such as the Ministry of Agriculture, Forestry and Food, and the Ministry of the Environment and Spatial Planning. The first one is relevant because of food safety and providing conditions for a healthier diet, and the second is relevant for decisions about locating spatial developments. In addition, we also work together with a number of civil initiatives, which are pretty dispersed in Slovenia today and usually focus only on individual problems in a wide variety of areas. Furthermore, governmental negotiations also form an important part of the responsibilities of the Ministry of Health.” − Spatial development and health are covered by separate policies in Slovenia. The Spatial Development Strategy of Slovenia (2004), which guides spatial development, includes health under social infrastructure. It defines the level of health services based on the function of the settle- ments within the spatial network. Then there’s the Strat- egy for the Development of Public Health Services. Could you evaluate how well these two politics take each other into account? “First we need to separate the provision of public health, which is only one segment of health provision and covers health at the macro-level. The primary care network is covered by the National Programme for Health Protection until 2013, which is already obsolete. Two aspects should be highlighted. The first aspect is locating the buildings for social infrastructure in the territory (primary services, emergency points and hospi- tals) considering principles of modern spatial planning such as physical accessibility and energy efficiency. However, there isn’t so much new construction, so it’s more accurate to talk about renewing existing buildings. The second aspect is broader and refers to whether all the policies are planned by considering their impact on people’s health. This aspect is a lot more com- plex and it’s also more demanding in the planning sense. For example, we’ve got an energy provision policy that should offer sustainable means of energy production; however, such devel- opment usually faces several barriers when it’s located. Or the existing strategies even contradict each other, especially if we look at the vertical dimension of preparing and implementing the policy (from the EU to the local level).” − Slovenian territory is influenced by several processes like demographic changes, emptying of the countryside and suburbanisation. Do these spatial processes also influence health policy? “The connection is very close; for example, provision of com- munal infrastructure impacts access to drinking water. Plan- ning neighbourhoods is connected to provision of recreation, sports and play facilities. Facilities like cycling paths should be provided to support sustainable mobility. In Slovenia the provision of some basic services is connected to the dispersed pattern of settlement or with a negotiation process with stake- holders, so that undesired development (for example, five houses instead of three in a certain location) is prevented. In Slovenia we used to have well-functioning social planning that followed key guidelines and it was also acted on according to them. Multidisciplinarity and coordination between sectors Urbani izziv, thematic issue, 2015, no. 1 66 Interview were important, but now each of them is busy with implement- ing European directives and (too) many norms. The health sec- tor can provide opinions about locating spatial developments; however, these are often only limited to measurable indicators like air quality, noise level and quality of drinking water. Stake- holders are also included into the planning process much too late, when the decision has usually already been made. We also have many strategies that aren’t legally binding. It’s also important to remember that an individual development might be positive for one part of the population, but negative for another part. The motorway is such a case: for some people, it offers economic development, new jobs and green industry, but, for others that live near it, it degrades the landscape and the quality of life.” − The Faculty of Civil Engineering and Geodesy has prepared an analysis of the state of the art, development trends and guidelines for strategic spatial development that also incorporates the network of public institutions. Is the current hospital network too broad and ineffective? “If we only talk about locating new buildings, it’s difficult to comment on whether all these hospitals provide the right ser- vices and if it makes sense for all of them to cover all services instead of being specialised. Even if one of them were closed, I doubt the quality of life would really improve. What should we do with the leftover infrastructure then? Transform it into a facility for the elderly or an intergenerational centre? Our hospitals need more specialisation; taking into account the motorway network and accessibility, this would probably be an advantage.” − What about the network of primary health centres? “The fact that there are sixty-five primary health centres is a leftover from the previous administrative framework, which was based on the division of Slovenia into sixty-five municipali- ties. In each of them, the health centre was the exclusive form of health provision at the primary level. Nowadays, in addition to these health centres, we’ve also got a network of conces- sionaires to complement the public services. Of course, there are areas in Slovenia where accessibility should be improved, especially with regard to emergency response. Also, what’s the point of being able to get to your doctor in five minutes if you have to wait fifteen months for a check-up? Therefore, in Slovenia local accessibility can’t be the only criterion and we need to overcome the thinking that the health centre is just a building where you need a minimum time to get from one office to another. The health centre should also be a consulta- tion office where services complement each other and treat the patient more holistically. Such an approach is a big challenge for providers. Blood samples can be collected and then even sent one hundred kilometres away to a lab for analysis, which might even be better for the patient. The leap to holistic health centres that also offer preventive treatment at the level of the whole community; this is certainly still missing.” − In a territorial sense, should services be condensed fur- ther in the larger urban areas or regional centres? “Currently, the services still aren’t concentrated enough. In public health provision there’s a noticeable slow but clear trend of concentration in large cities with bigger regional hospitals. This is something that everyone probably wishes for. Like I said, the primary health centres are not the only caretakers for primary health services, but they’re complemented by a concession network. And for the concession network we don’t want concentration. However, then the problem is that doctors don’t want to take jobs in the periphery, which in the end isn’t the fault of spatial planning but of conditions, perception and means of financing: what do you lose if you live in [remote locations like] Tolmin or Haloze in comparison to living in cities like Celje or Ljubljana, which, like I said, in the end isn’t a matter of physical planning. Therefore, not only the infrastructure aspect should be assessed, but other aspects too, like public amenities  – for example, green infrastructure or providing a barrier-free environment – which aren’t the major domain of the hospitals and health centres.” − A new concept has been introduced in urban planning: healthy urban planning targeted at providing a territory that also changes behavioural patterns by providing green areas. How successful do you think Slovenia is at provid- ing soft measures like that for providing a healthy environ- ment? “I think a lot has already been done in this area. For exam- ple, for providing food, the public procurements legislation has been changed, and it was a big obstacle before. Providing quality food is a big opportunity, especially for sustainable lo- cal provision and short supply chains. This doesn’t necessar- ily mean only organic food; the fact that the food is locally produced already suffices. The problem could be on the sup- ply side. When Slovenia entered the EU, people were happy to see glittering new shopping centres that offer food at very low prices that small-scale local providers can’t compete with. On the demand side, we’ve got the problem that a school or a hospital needs a guaranteed 365-day-a-year quality food supply that local farmers can’t provide. Cooperatives have somehow been lost in the process. An important further step is now the new strategy of the Ministry of Agriculture, Forestry and Food. As the Ministry of Health, we prepared the food supply policy back in 1996, which also integrated local sustainable provision and short supply chains as a priority, but our ideas weren’t understood at that time. Now the times have changed and food self-sufficiency is more than ever part of national policy. Urbani izziv, thematic issue, 2015, no. 1 67Interview “In addition, there are two more aspects I want to mention: first, how we want to improve the territory. For example, in Slovenia  – in Maribor  – we’ve got urban gardens that are a result of a municipal initiative that spent eighty thousand euros to refurbish a degraded area for local people to produce food in live with agreed-upon rules. As reported, the most difficult part was respecting the basic rules and winning the respect of other users. When this was achieved, the urban garden com- munity started living on its own. Such opportunities are really rising now, which is also important for people from the social aspect. The second aspect is spatial planning of future large infrastructure projects, like the construction of power lines, which can affect people’s health, and so early and high-quality inclusion of the public in spatial planning processes is vital. If Slovenia decides to introduce renewable sources of energy like wind farms, it also has to take into account their impact on people’s health; this means they need to be located at a safe distance from where people live. “Before a strategy is adopted in Slovenia, one should consider whether there’s any suitable land available for site-specific de- velopments. Assessing the impact on people’s health can also be useful for improving inter-sectoral cooperation in locating spatial developments. This is a new method in public health, and using well-grounded assessments of potential impacts of various policies on health makes it possible to adopt informed political decisions.” − As can be seen in your answers, it isn’t clear who should be responsible for delivering a healthy environment. Can civil society do more than the state? Who should play a more important role? “A healthy environment isn’t something decided only by peo- ple, but is also governed by several European directives, and by taking them into account we can provide high-quality drinking water, surface water, groundwater and water for swimming, as well as good air quality. The state will need to pay a fine to the European Commission if the air quality in Ljubljana isn’t good enough  – although, theoretically, is this really always feasible? Environmental legislation is in place, defining the ba- sic principles of environmental protection and also protecting human health, wellbeing and quality of life. But I agree, the division of responsibilities isn’t always clear because these are areas where the responsibilities of the ministries of the environ- ment and health overlap; for example, the directive on water in natural swimming areas (rivers and lakes) is now covered by the Ministry of the Environment and Spatial Planning, even though the initial idea was for the Ministry of Health to be in charge of this. Although some of the areas are very strictly regulated, others, like managing degraded or overly polluted areas, are regulated quite poorly or not at all.” − You’ve already touched a bit on coordinating the sec- tors. There’s a document from 2012 called “An Overarch- ing Approach for People’s Health and Wellbeing of and Diminishing Inequalities in Health” that talks especially about the need for coordinating health and other policies. In your opinion, what’s the biggest obstacle preventing cooperation from being delivered better? “Our health is a sign of some structural elements in society. Poor and deprived people die sooner, are sicker, and are prac- tically at the end of the list on all variables. Stereotypes like the ones about capable managers dying young because of heart attacks aren’t true. The poor and unemployed are the sickest and don’t have a light at the end of the tunnel. So, from the point of view of health policy, it’s very important to main- tain the social network and the level of equality because in the long term society can only benefit from that. Today, we mostly forget about that. And, of course, it’s very important for us to tell this to the decision-makers because it’s relevant for the policies concerning spatial integration, labour, and social and education policy. There are several problems: the tools for policy evaluation exist, but there’s the problem of administrative capacity: at the Ministry of Health we can’t perform this function in the long term or staff-wise because we’re understaffed. Currently the directorate employs twenty people that cover twenty-five priorities together. Other coun- tries have developed criteria and tools, and they educate ad- ministrators in evaluation. There are other ministries and their policies that act beneficially towards health; for example, the rural development policy or rules regarding road safety, which is reflected in statistics on injuries, deaths and so on. In the end, everything depends on the political will and priorities of a particular minister. If the priority is for people to be healthier, so they can work longer and benefit society, than we need relevant measures for that and then we also need to provide the monitoring. So far in Slovenia, we haven’t arrived at that point yet. The third element I’m missing is public discourse. In our media space, we’re bombarded with banal matters, but we don’t really talk about the important ones. Such topics also include administrators’ general knowledge. It’s not that they’re ignorant, but they don’t have many opportunities for training because this knowledge isn’t part of the university curriculum. Then during the dialog we realise that the only thing we need is a little more understanding and to look at things from a different perspective.” − The Spatial Development Strategy of Slovenia is being revised. What do you recommend integrating into the document? “The spatial planning strategy should integrate the goals of health, wellbeing and quality of life. Enough safe green ar- eas that allow physical activity and social inclusion should be Urbani izziv, thematic issue, 2015, no. 1 68 Interview provided. Greater emphasis should be placed on vulnerable groups. People that are generally well off will take care of them- selves; they’ll drive to access services, go to the gym and do sports. We need to help people who are socially disadvantaged; they have to be actively included and provided with spatial arrangements that encourage healthy lifestyles in their local environments. I’d say there’s not enough thinking along these lines. Today quality of life is only reserved for people who are better off and so their neighbourhoods need to be planned with the highest quality in mind.” − To conclude, how do you usually look after your own health? “Personally, I try to live a balanced life, which should be the result of regular sports activities, a balanced diet and a balanced work and family life.” – On behalf of the Slovenian SPHERA team and person- ally, I’d like to express thanks to you as an observer in the SPHERA project, for your engagement in the SPHERA project through this interview and for your participation in the SPHERA national seminar. This text is based on a group interview conducted by Naja Marot, 29 May 2014. Naja Marot University of Ljubljana, Biotechnical Faculty, Ljubljana, Slovenia E-mail: naja.marot@bf.uni-lj.si