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40 
 
Slovenian health care system performance in the light of Euro 
Health Consumer Index 2012 
Zmogljivost sistema zdravstvenega varstva Slovenije z vidika 
Euro Health Consumer Index 2012 
Jerneja
 
Farkas*
1
, Tit Albreht
2
 and Lijana Zaletel-Kragelj
1
 
1 
Chair of Public Health, Faculty of Medicine, University of Ljubljana / Zaloska cesta 4, Ljubljana, Slovenia 
2 
Institute of Public Health of the Republic of Slovenia / Trubarjeva ulica 2, Ljubljana, Slovenia 
 
E-mail: jerneja.farkas@mf.uni-lj.si 
 
Abstract: Health care systems are complex entities with several stakeholders that include patients, health care 
providers, payers, regulators and government. For lay and professional public, the methodology of health care 
system performance analysis, result interpretation and translation to policy making is not well understood. 
Slovenian health care system performance results from a Swedish health care analyst (Euro Health Consumer 
Index 2012) and opportunities for improvement are discussed. We specifically addressed methodological 
challenges of international health care system performance comparisons.  
Key words: comparison; health care system; indicators; Slovenia 
Povzetek: Sistemi zdravstvenega varstva so kompleksni sistemi s številnimi deležniki, med katerimi so 
najpomembnejši uporabniki in izvajalci zdravstvenih storitev, plačniki, regulatorji in odločevalci. 
Metodologija ocenjevanja zmogljivosti sistemov zdravstvenega varstva, interpretacija rezultatov in prenos v 
načrtovanje zdravstvenih politik so tako za laično kot tudi za strokovno javnost pogosto slabo razumljivi. V 
prispevku predstavljamo rezultate, ki jih je v sklopu mednarodne primerjave sistemov zdravstvenega varstva 
Euro Health Consumer Index 2012 prejel slovenski sistem in razpravljamo o možnostih za izboljšanje. Posebej 
se osredotočamo na metodološke pomanjkljivosti, ki jih mednarodne primerjave sistemov zdravstvenega 
varstva lahko vsebujejo. 
Ključne besede: primerjava; sistem zdravstvenega varstva; kazalniki; Slovenija 
 
1. Introduction 
Health care systems are complex entities with several 
stakeholders including patients, health care providers, 
payers, regulators, government and the lay public. The 
fundamental goal of health care systems is to improve the 
health of patients and of the general population (1). 
Although outline and goals of health care systems are 
straightforward and well defined, they may not be met in 
daily practice. Various objective and subjective reasons 
contribute, and many are beyond health care system itself. 
Even when declaratively similar health care systems are 
compared there may be marked differences in professional 
roles, in coordination mechanisms and in care settings. 
Hence, the context in which different health care systems 
were developed and operate can vary largely and those can 
be two main independent variables that also limit 
comparability. To compare performance of health care 
systems, a detailed and comprehensive approach is needed 
but even then the quality of results can be argued. 
Performance measurement is used to monitor, evaluate 
and communicate the extent to which various aspects of 
the health care system meet key objectives (1). Ability to 
provide relevant, accurate and timely performance 
information is essential to reach, maintain and improve the 
performance of health care systems and to identify where 
there is room for improvement (2). Records of 
performance measurement efforts in health care systems 
can be traced back at least 250 years (3). More formal 
arguments for the collection and publication of 
performance information were developed only about 100 
years ago, because pioneers in the field were continuously 

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challenged by various professional, practical and political 
barriers (1, 4). According to Smith and colleagues, we have 
witnessed dramatic growth in health care system 
performance measurement and reporting over the last 25 
years (1). 
Performance measurement begins with a decision on 
what to measure, continues with an identification of the 
appropriate measures and their data sources, and ends with 
an analysis, aggregation, interpretation, and result 
reporting (4). Following fundamental goal of health care 
systems, many instruments have focused either on 
measures of the patient clinical outcomes or on population 
health measures. The former usually include indicators as 
appropriate drug prescribing, regular glucose monitoring 
for diabetics or blood pressure monitoring for 
hypertension, whereas the latter have traditionally been 
presented with standardized mortality rates, life 
expectancy, years of life lost or disability-adjusted life 
years. Since many performance measures are provided for 
different aspects of the health care system, the information 
can become complex and difficult to understand. 
Therefore, composite indicators are becoming increasingly 
popular. If not carefully designed, they may be misleading 
and cause serious fallacies when used for health care 
system policy-making or planning. The fundamental 
challenge of composite indicators is to select measures to 
include in the individual indicator and to assign the 
weights (1). Because different types of performance 
measures, as well as composite indicators, are frequently 
applied in international comparisons of health care system 
performance, adequate caution must be used in interpreting 
such results.  
For lay and professional public, the methodology of 
health care system performance analysis, result 
interpretation and translation to policy making is not well 
understood. Slovenian health care system performance 
results from a Swedish health care analyst (Euro Health 
Consumer Index 2012) and opportunities for improvement 
are discussed. We specifically addressed methodological 
challenges of international health care system performance 
comparisons. 
2. Characteristics of Slovenian health care system 
Before placing Slovenian health care system in the light 
of international comparison with other European countries, 
certain level of background information about health care 
system organization is necessary. In Slovenia, the debate 
whether health funding should be based on general taxation 
or social insurance, ended in favour of Bismarck type of 
social insurance system. Since 1992, previously 
exclusively publicly financed system has been transformed 
into a mixed system (11). Namely, in 2008 the share of 
health expenditure from private health insurance 
institutions was 13.1% and from direct payments by 
households 13.5% (12).  
In the last two decades, Slovenia has transferred from a 
communist regime into a democratic system, thus large-
scale political, socio-demographic, and economic changes 
have taken place. In the year 2003 the number of people 
over 65 years had exceeded the number of people aged less 
than 15 years and differences among those two population 
groups are increasing ever since (13). In 2010, the 
proportion of older people increased to 16.5% (14), and 
this number is projected to reach 30.2% by the year 2030 
(15). Although morbidity and mortality data show that 
Slovenia experiences same scenario as other countries in 
Western and Central Europe, high rates of suicide (18.7 per 
100,000 in 2009) and deaths caused by chronic liver 
diseases and cirrhosis (24.8 per 100,000 in 2009) are 
reasons for concern (16). By taking into account the aging 
of the population and the rapidly increasing number of 
chronically ill people, expansion of coverage, development 
of more expensive health technologies and increased 
population expectations, the pressure on Slovenian health 
care system is constantly rising.  
According to Rechel and McKee, major health reforms 
in countries of Central and Eastern Europe have included a 
reduction in size of the hospital sector, expansion of 
private providers, decentralisation, a change in methods of 
payment for providers, and efforts to improve public health 
and quality of care (17). In Slovenia, the number of 
hospital beds has been decreasing since the 1980s. This 
was a consequence of a process focusing on management 
of acute conditions and elective procedures, as well as of a 
planned shift to more outpatient-oriented care. As a result 
of this policy, the overall number of hospital beds 
decreased gradually by approximately 30% (from 695 per 
100,000 population in 1980 to 470 per 100,000 in 2008) 
(10, 12, 16, 18). This process was also assisted by 
significant changes in the hospital reimbursement systems, 
including the shift from bed-day payments to case-based 
payments, as well as the introduction of diagnosis-related 
groups (11). Partial privatisation within the health care 
system has taken place gradually (19); however, the 
Slovenian health care system remains relatively centralized 
and the responsibility of municipalities is still limited. In 
2008, the total health expenditure accounted for 8.3% of 
GDP (12). Among the European Union (EU)-12 countries 
(that joined the EU in 2004 and 2007), Slovenia ranked 
first in terms of per capita spending and first in terms of 
their share of GDP spent on health (11). In order to 
produce health, health care systems should address the 
needs of their populations (20). Therefore, there is a 
growing awareness that a public health perspective should 
be incorporated in health system governance practices (21, 

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22). The main problem encountered in terms of health 
promotion, as in other countries, is adequate support and 
interest by political decision-makers for health promotion 
in the future development of the health care system (11).  
3. International comparisons of health care systems 
Although the international comparisons of health care 
systems present some methodological challenges due to 
differences in national definitions or methods of data 
collection (5), there is growing interest in such 
comparisons. According to Veillard and colleagues, there 
are three major reasons for that: accountability, which 
enables countries to compare their performance with that 
reported in other countries, strategy development, and last, 
but not the least important, mutual learning (6). 
International comparisons of health care system 
performance provided by multilateral organizations such as 
World Health Organization (WHO) and the Organization 
for Economic Cooperation and Development (OECD) 
attracted much attention (6).  
In the year 2000, WHO carried out the first ever 
analysis of the world's health care systems using five 
performance indicators in 191 member states (7). In 
designing the framework for health care system 
performance, WHO entered new methodological ground 
by employing a technique not previously used for health 
care system analysis. It compared each country's health 
care system to what the experts estimate to be the upper 
limit of what can be done with the level of resources 
available in that country. It also measured what each 
country's health care system has accomplished in 
comparison with those of other countries. WHO's 
assessment was based on five indicators: overall level of 
population health, health inequalities (or disparities) within 
the population, overall level of health care system 
responsiveness (a combination of patient satisfaction and 
how well the system acts), distribution of responsiveness 
within the population (how well people of varying 
economic status find that they are served by the health 
system), and the distribution of the health care system's 
financial burden within the population (who pays the costs) 
(8). According to that analysis France provided the best 
overall health care followed by Italy, San Marino, Andorra, 
Malta and Singapore. In Europe, health care systems in 
Mediterranean countries were rated higher than others in 
the continent and Norway was the best ranked 
Scandinavian nation in 11
th
 place, whilst Slovenia was 
ranked as 38
th
 (8). Despite many criticisms, “The World 
Health Report 2000” placed international health care 
system performance on the political agenda, raised 
awareness about performance issues and resulted in many 
initiatives to improve the perceived health situation across 
the globe (6). 
Health care systems have been continuously forced to 
improve performance by restricting expenditures while 
maintaining steady improvements in access and quality (9). 
As a consequence, many international comparisons of 
health care systems were based on national health care 
expenditures of OECD member countries, measured either 
as a percentage of gross domestic product (GDP) or on a 
per capita basis (9). Latest data on different aspects of the 
performance of health care systems across the OECD 
member countries were published in “Health at a Glance 
2011” (10). Key performance indicators provide 
information on health status, the determinants of health, 
health workforce, health care activities, quality of care, 
access to care, health expenditure and financing as well as 
long-term care in OECD countries (10).  
The Health Consumer Powerhouse, Swedish health 
care analyst and information provider introduced the 
Swedish Health Consumer Index in 2004 to compare 21 
county councils by 12 basic indicators concerning the 
design of systems policy, consumer choice, service level 
and access to information. Next year this concept was 
transferred to a pan-European level with its first Euro 
Health Consumer Index (EHCI). The EHCI 2012 assessed 
34 European health care systems based on 42 health care 
performance indicators structured to a framework of 5 sub-
disciplines: Patient rights and information, Accessibility 
(Waiting times for treatment), Outcomes, 
Prevention/Range and reach of services provided, and 
Pharmaceuticals (23).  
4. Euro Health Consumer Index 2012 score for 
Slovenian health care system 
According to the EHCI 2012 the Slovenian health care 
system was ranked 19
th
 among 34 European countries, 
scoring 638 points out of 1,000 (23). Slovenia was among 
the highest ranked Central and Eastern European countries 
and did well in the areas of Patient rights and information, 
Outcomes and Pharmaceuticals. The following 
performance indicators were given the highest rating: 
health care law based on patients’ rights, right to second 
opinion, same day access to the family doctor, low infant 
mortality rate, low rate of births by Caesarean sections, 
inclusion of the dental care in the public health care 
financing, layman-adapted pharmacopoeia readily 
accessible by the public, appropriate deployment of 
medications for Alzheimer disease, and high public 
awareness of the lack of efficiency of antibiotics against 
viruses (Table 1) (23). EHCI 2012 stated that in the past 
years Slovenia has introduced certain novelties in the 
domain of access to specialist, no-fault malpractice 

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insurance, and the right to second opinion, together with 
considerable improvement in the area of access to 
information (e.g. register of legit doctors, layman-adapted 
pharmacopoeia, and even an attempt to construct a true 
providers’ catalogue with quality ranking); some of these 
changes being attributable to the introduction of an “Act on 
Patients’ Rights” in 2008 (23).  
In general, Slovenian health care system scored worst 
in the Accessibility (Waiting times for treatment) sub-
discipline. The lowest rates were also applied to some of 
the indicators included in the Patient rights and information 
sub-discipline (e.g. cross-border care mobility, existence of 
health care provider quality ranking catalogue, and 
functional e-prescription service), Prevention/Range and 
reach of services provided sub-discipline (e.g. number of 
cataract operations, rate of mammography in females aged 
50-69 years, and share of dialysis done outside of clinics), 
and to single indicator in Outcomes sub-discipline (e.g. 
prevalence of undiagnosed diabetes) – Table 1. 
We performed less well in terms of the e-health 
indicators, which were also part of the Patient rights and 
information sub-discipline. Our results were especially 
poor in the introduction of e-prescriptions service (the 
percentage of general practitioners’ (GP) practices which 
can send prescriptions electronically to pharmacies). A role 
model in this field is Sweden with its centralized pharmacy 
system. More than 85% of all prescriptions are sent to a 
central e-mailbox, and the patient can then walk into any 
pharmacy in the country, where they simply pull down the 
prescription from the mailbox (23). However, in terms of 
e-health infrastructure, Slovenia scores better than EU 
average: 97% of GP practices owe a computer, 83% are 
connected to the Internet and 54% having access to a 
broadband Internet connection (24). When compared to the 
other Central and Eastern European countries, Slovenia is 
second after Estonia. The use of e-health applications 
however is considerably lower. The rather low use rates 
attained by Slovenian GPs in the area of e-health 
application can be partially explained by the fact that 
Slovenian e-health strategy is relatively new. The 
government published the “e-Health 2010 Strategy” as late 
as in December 2005. Next year a Council for Health Care 
Informatics was established with the aim to promote 
information and communication technology use in the 
health care system in general and to foster the 
establishment of appropriate standards (24). Considering 
EHCI 2012 ratings, e-health solutions remain a challenging 
issue and several projects are currently on-going in order to 
implement “e-health 2010 Strategy” and to improve 
outcomes in the years to come.  
The key area, where Slovenia performed poor is the 
Accessibility (Waiting times for treatment) sub-discipline, 
particularly in the following indicators: direct access to 
specialist (can patient see a specialist without a referral 
from a primary care doctor), major non-acute (elective) 
operations in less than 90 days, and CT scan in less than 7 
days (time to get a CT scan after referring doctor’s 
decision) (23).  
Slovenia is an example of a country where GPs have a 
gatekeeping role in the health care system. Patients do not 
have direct access to secondary care level; they need a 
referral from their GP. In addition to GP, who acts as a 
personal physician, children are required to have a personal 
paediatrician and women have the opportunity to choose a 
personal gynaecologist. Therefore, direct access to those 
two specialists is possible. Of course, all insured 
individuals in Slovenia have access to health care at the 
secondary care level in the case of an emergency or in the 
event that personal doctors decide that delaying the 
treatment would cause an irreversible damage to the 
patient’s health. In past years, waiting times existed 
especially in the area of orthopaedics (hip and knee 
replacement), open heart surgery, coronary angiography 
and balloon dilation, for cataract and thyroid gland surgery, 
as well as for some more demanding diagnostic tests (for 
example, MRI scanning) (11). Since this had particularly 
involved patients with chronic disease and elderly patients, 
these groups were particularly affected by the waiting lists. 
Various measures, including increased funding for health 
care providers in areas in which excessive waiting times 
existed, have been adopted by the Ministry of Health and 
the Health Insurance Institute of Slovenia in order to 
abolish or reduce waiting times (11). As a result, long 
waiting lists have been partially reduced but the problem is 
far from being solved. There are various opinions as to 
why waiting times still exist and in some areas even 
continue to increase (e.g. knee replacement, peripheral 
vessel disease surgery) (25). Health care providers claim 
that it is because of insufficient funding; while some 
hospitals claim that it is due to the lack of human resources, 
space and equipment. Given that there were very different 
data concerning effective waiting list times in different 
hospitals, a decision was taken that a national waiting list 
for several most common conditions should be formed. In 
order to support such an approach, a web-based solution 
was developed, which offers information on waiting list 
times to patients and their relatives as well as to their GPs, 
prevent repetition of input of the same patient, as well as 
set some benchmarking goals for hospitals among 
themselves in order to aim for reduction in waiting list 
times (26). Due to the “Regulation on maximum 
acceptable waiting times for individual health care services 
and on management of waiting lists”, every health care 
provider had to introduce a waiting list manager, whose 
responsibilities include prompt updating of waiting lists. If 
the waiting time for certain health care service is beyond 

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acceptable, health care provider has to inform the patient 
about the possibility of management in an alternate 
institution with acceptable waiting time (27). However, 
this is one of the few indicators, where traces of financial 
crisis show up: waiting times for (expensive) elective 
surgery seems to have increased, most notably in countries 
severely hit by the crisis (23). 
According to EHCI 2012, Slovenia has to increase the 
percentage of women aged 50-69 years screened for breast 
cancer. There are intense and comprehensive activities in 
the field of prevention and management of cancer burden. 
Firstly, being aware of this major public health problem, 
our Government has chosen cancer as the central topic for 
the Slovenian EU Presidency during the first half of 2008. 
Secondly, Slovenia can build on a number of strengths, 
including the population-based Cancer Registry, which 
systematically collects cancer epidemiology data on a 
national scale. Although different cancer control activities 
have been in place for many years, a comprehensive 
national cancer control programme, based on a systematic 
assessment of the strengths and weaknesses of existing 
services for cancer prevention and the clinical management 
of cancer patients has recently been developed (28). 
Important part of national cancer control programme is 
promotion of 3 cancer screening programmes: cervical, 
breast, and colorectal cancer screening (28). Finally, breast 
cancer screening programme started in April 2008 for 
women aged 50-69 years residing in Ljubljana 
municipality. First response rates (73.8% after first 
invitation) were encouraging, since this was higher than in 
comparable pilot programmes of other countries that have 
introduced organised screenings for breast cancer (29). By 
establishing new screening units the plan was to gradually 
expand the programme to other geographical areas and to 
cover the target population of the whole Slovenia. Besides 
screening units, quality of the organization of screening 
programme is of essential importance. The key elements of 
a high quality screening programme include the 
appropriate education and professional qualification of the 
personnel, primarily radiologists and radiological 
engineers, and also of other personnel participating in 
further diagnostics and treatment, double blind reading of 
mammograms, interdisciplinary cooperation, appropriate 
technical quality of mammography machines, appropriate 
information system, and monitoring and evaluation of 
program quality indicators (30). Currently, continuous 
efforts are under way to overcome organizational barriers 
and cover larger geographical area (29). This would not 
only increase the percentage of women screened for breast 
cancer, but also allow the program to move closer to 
achieving its ultimate goal of reducing mortality from 
breast cancer in Slovenian women. 
Diabetes mellitus affects a large number of people 
worldwide and the number of newly diagnosed cases is 
rising. As EHCI 2012 results show, the prevalence of 
undiagnosed diabetes is high in Slovenia. Although the 
indicator that Health Consumer Powerhouse really desired 
for was percentage of diabetics with high HbA1c levels 
(above 7.0%), they were unable to find any sort of reliable 
data for a significant number of countries. For this reason, 
they decided to follow data from the International Diabetes 
Federation Atlas for the 2012 analysis (23). On the other 
hand, the same health care analyst provided Euro 
Consumer Diabetes Index in 2008, where percentage of 
diabetics with HbA1c levels above 7.0% was included. 
HbA1c is an important assessment tool of how well 
diabetes has been managed on individual patients for the 
previous two or three months. From the states reporting 
data, there were ten countries (Austria, Belgium, Cyprus, 
Denmark, Estonia, Lithuania, Norway, Poland, Slovenia, 
and Spain) that have more than 50% of patients with 
HbA1c levels above 7.0%. However, some of them explain 
that many of the patients included in these 50% stay 
between 7.0 and 7.5% (31). The continuing growth of 
diabetes places an increasing drain on health care system. 
For purposes of preventing complications it is crucial to 
maintain a good glucose balance and to avoid the risk 
factors for arterial disease. It is at least equally important to 
alleviate the situation through improved self-care. In 2010, 
Slovenian Ministry of Health launched “National 
programme on management of diabetes mellitus 
(Development Strategy 2010-2020)”, which incorporates 
objectives, responsibilities, financial support, interventions, 
and quality control at all levels (32). 
EHCI 2012 pointed out the low number of dialysis 
performed outside of clinics. In Slovenia, there are 21 
dialysis centers. According to Slovenian nephrologists the 
interest of patients for home dialysis was sporadic. This 
type of dialysis is more frequent in countries where 
distances to the dialysis centers are longer, but also in 
some countries, where quality of treatment in dialysis 
centers is suboptimal. In addition to clear benefits (e.g. no 
transport, no waiting for the dialysis, staying in home 
environment), there are also some disadvantages: problems 
with the stabbing, responsibility for the appropriate care of 
the dialysis apparatus and supplies, control of the 
procedure, burden for the family, issues of loneliness and 
isolation of the patient. At this time, funding and logistics 
for the dialysis at home are not formally regulated in 
Slovenia. Nevertheless, the debate about combining home 
dialysis with dialysis in centers (for example, once every 
two or four weeks) is starting, as well as initiatives for 
greater flexibility in dialysis centers (33). 

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5. Challenges and opportunities for Slovenian health 
care system 
At a time when the number of elderly and chronically 
ill is constantly rising and when economic downturn is 
enlarging health inequalities, the need for efficient and 
sustainable health care system is more important than ever. 
In addition, new medical technologies, pharmaceutical 
innovations and increasing population expectations, speed 
the growing of health care expenditure. The discrepancy 
between the needs and demand for advanced diagnostic or 
treatment options and long-term care services are 
becoming another burning issue. The health care system 
must become more competitive and development-oriented 
and needs redefinition of a basic basket of health care 
rights as well as of public-private partnerships (34). 
Current situation demands more funds and attention, as 
well as it requires additional skilled human resources.  
Another chronically unresolved issue in Slovenian 
health care system is the shortage of medical doctors, 
which makes implementation and health care quality 
maintenance very difficult. Although the number of 
medical doctors has been growing somewhat more strongly 
in recent years, Slovenia’s gap to the EU and OECD 
average nevertheless continues to increase. Slovenia lags 
behind most notably in the number of general practitioners 
(49.8 per 100,000 population in 2010; in the EU-27: 87.4 
per 100,000 population in 2009), which is problematic as 
regards both access to health care services and the cost-
effectiveness of the health care system. In 2010 and 2011, 
Slovenia took certain measures to strengthen primary 
health care and take some burden off the general 
practitioners: firstly, introduction of new training primary 
health care offices, in which doctors specialising in general 
medicine can register their patients (under tutorship); 
secondly, introduction of reference primary health care 
offices, in which registered nurses assume greater 
responsibilities; and thirdly, additional funding for the 
primary health care (35). Hence, the challenge for the 
future is to ensure the continuous development of human 
resources.  
Recently, the scope and impact of medical errors 
enticed national efforts to address this problem. According 
to Leape and colleagues, safety does not depend just on 
measurement, practices and rules, nor does it depend on 
any specific improvement methods; it depends on 
achieving a culture of trust, reporting, transparency and 
discipline. For health care organisations in every country, 
this requires a major cultural change (36). Education and 
training in the areas of quality and patient safety should 
become an integral part of the curricula of all health 
education institutions and programmes, as well as of 
internal education programmes in each health care 
organization, and requirements related to quality and 
patient safety should be included in the education and 
training of health care providers. Continuous development 
of individuals also needs to be ensured through acquisition 
of new knowledge in the areas of quality and patient safety, 
and development of social and personal skills and 
behaviours (such as doctor–patient communication) (11). 
Additionally, introduction of a medical error reporting 
system would also help to prevent easily avoidable 
mistakes with potentially serious consequences.  
6. Methodological challenges of international health 
care system comparisons 
International health care system comparisons may 
constitute a rich source of evidence as well as powerful 
influence on policy (37). If undertaken carefully, such 
comparisons offer a powerful resource for identifying 
weaknesses and suggesting relevant changes. However, its 
full potential is currently limited by several problems. 
Country comparisons that are not conducted with properly 
validated measures and unbiased policy interpretations 
may prompt adverse policy impacts and so caution is 
required in the selection of indicators, the methodologies 
used, and the interpretations made (37). Another problem 
is selecting certain indicator areas as being more important 
than others and multiplying their scores by numbers other 
than one. Definitions of performance indicators should be 
clear and consistent, and fit into a clear conceptual 
framework. The metrics used should have widespread 
acceptance and certain adjustment for variations in the 
demographic, social, cultural and economic circumstances 
of nations is necessary. Furthermore, single number 
measures of whole health care system performance, while 
offering a more rounded view of performance, have limited 
scope for policy action, and may distract policy-makers 
from seeking out and remedying the parts of their system 
that require attention (37).  
Some attempts to compare health care systems are 
sporadic and therefore many vital contributors for system 
performance may not be considered. The Health Consumer 
Powerhouse, on the other side, has been publishing a wide 
range of comparative analyses since 2004. As such it has a 
considerable potential to overcome many of the limitations 
observed in sporadic comparisons. However, definitive and 
precise comparisons are challenged because indicators are 
assigned different weights in yearly analysis and over time. 
Some inconsistency of total score, although several 
indicators are repetitively used may further introduce a 
selection bias.  
 
 

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7. Conclusions 
Concerning various comparisons of the health care 
systems, we should be aware of the used data sources 
quality and reasons for the selection of specific 
performance measures. The quality of data varies between 
countries, which limits exact comparisons. Furthermore, 
we should be careful when weighting of certain composite 
indicators were applied and if possible changes in indicator 
definitions appeared through years. Consequently, a careful 
consideration of possible approaches to interpreting 
international comparisons of health care system 
performance is needed. 
European health care systems, including Slovenian, 
need to find a balance between the values they are 
committed to while striving for efficiency and competition, 
providing options that benefit the society and help contain 
health care expenditure, in particular to meet the challenge 
of an increasingly ageing population. Management of 
chronic diseases demands a different type of care 
organisation than management of acute conditions. The 
emphasis is on care (rather than cure), on monitoring 
(rather than acute interventions), and on a multidisciplinary 
approach and creation of integrated care networks (21, 22). 
In order to establish a health care system, which would 
optimally meet the needs of the population, we should 
focus on population health consideration as well.  
As no structural changes have been implemented in the 
previous decade, it is of utmost importance that Slovenia 
implements the reform of the health care system (12). 
Soon, Slovenian patients and health care professionals will 
be faced with rewriting of Health Care and Health 
Insurance Act regulating the system of financing and 
Health Services Act regulating the operation and 
management by health care providers (12), which should 
also address those issues. 
Table 1: Euro Health Consumer Index 2012 scores for Slovenia according to individual performance 
indicator. 
Sub-discipline Indicator Slovenia 
 
 
 
 
 
1. Patient rights and 
information 
1.1 Health care law based on patients’ rights 
 
1.2 Patient organisations involved in decision making 
 
1.3 No-fault malpractice insurance 
 
1.4 Right to second opinion 
 
1.5 Access to own medical record 
 
1.6 Register of legit doctors 
 
1.7 Web or 24/7 telephone health care info with interactivity 
 
1.8 Cross-border care seeking financed from home 
 
1.9 Provider catalogue with quality ranking 
 
1.10 Electronic patient record penetration 
 
1.11 Patients’ access to on-line booking of appointments 
 
1.12 E-prescriptions 
 
 
2. Accessibility 
(Waiting times for 
treatment) 
2.1 Family doctor same day access 
 
2.2 Direct access to specialist 
 
2.3 Major elective surgery <90 days 
 
2.4 Cancer therapy <21 days 
 
2.5 CT scan <7 days 
 
 3.1 Heart infarct case fatality 
 

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47 
 
 
3. Outcomes 
 
 
3.2 Infant deaths 
 
3.3 Cancer deaths relative to incidence 
 
3.4 Preventable years of life lost 
 
3.5 MRSA infections 
 
3.6 Caesarean sections 
 
3.7 Undiagnosed diabetes 
 
3.8 Depression 
 
 
 
 
 
4. Prevention/Range and 
reach of services provided 
4.1 Equity of health care system 
 
4.2 Cataract operations 
 
4.3 Infant 4-disease vaccination 
 
4.4 Kidney transplants per million population 
 
4.5 Dental care included in the public health care offering 
 
4.6 Rate of mammography 
 
4.7 Informal payments to doctors 
 
4.8 Smoking prevention 
 
4.9 Long term care for the elderly 
n.a. 
4.10 % of dialysis done outside of clinic 
 
 
 
 
5. Pharmaceuticals 
5.1 % of public subsidy for total drug sales 
 
5.2 Layman-adapted pharmacopoeia 
 
5.3 Novel cancer drugs deployment rate 
 
5.4 Access to new drugs 
 
5.5 Alzheimer drugs 
 
5.6 Schizophrenia drugs 
 
5.7 Awareness of the efficiency of antibiotics against viruses 
 
The performance of the individual national health care system was graded on a three-grade scale for each indicator: green 
=good, yellow =so-so and red =not so good. After applying weight coefficients in each sub-discipline a green score 
earns 14.59 points in Patient rights and information sub-discipline, 50.00 points in Accessibility (Waiting time for 
treatment) sub-discipline, 37.50 points in Outcomes sub-discipline, 17.50 points in Prevention/Range and reach of services 
provided sub-discipline and 14.29 points in Pharmaceuticals sub-discipline (23). 
n.a.=non applicable  
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