5. Return-to-work policies in Slovenia for persons with health problems or disabilities
Vocational rehabilitation for persons with health problems or disabilities is a significant element of Slovenia’s policy landscape. However, the setup is not conducive to good employment outcomes, for several reasons. These include the fact that the disability insurance and the employment service offer a very similar type of intervention under a different name for a different target group – while using the same rehabilitation providers. Well intended, vocational rehabilitation provided by the disability insurance has a strong focus on the workers previous job and employer – except that this comes at a time when workers have been away from work for years. Vocational rehabilitation of the employment service seems least effective for recipients of a partial disability benefit – again reflecting problems of late intervention. Finally, Slovenia has a considerable network of occupational physicians – but they are busy with tasks that have little impact on employment. Better outcomes of return-to-work policies now in place can only be achieved by a holistic reform, with a view towards early intervention and a much stronger connection of the actions of various stakeholders and institutions.
This section discusses all those elements in the Slovenian social protection system that contribute to helping people at risk of dropping out of employment for reasons of ill health or disability to remain in or return to the labour market. This includes vocational rehabilitation services offered during different phases of the process and employment programmes by the Employment Service of Slovenia, but also issues related to the role of employers and occupational doctors, and the timing of medical rehabilitation.
5.1.1. Legal framework and organisation of vocational rehabilitation
Return to work for persons with health problems or disability is regulated in two main acts. The first is the Pension and Disability Insurance Act (ZPIZ-2), which specifies the social protection and vocational rehabilitation of persons with disability. The second is the Vocational Rehabilitation and Employment of Persons with Disability Act (ZZRZI), which comprises the assessment and employment rehabilitation of registered jobseekers with health barriers to employment.1 National budget and special-purpose funds are the main source of income funding these programmes.
Both ZPIZ-2 and ZZRZI specify that the right to employment (re)integration only cover people with a legally confirmed disability status. A person is entitled to a legal disability status and rights derived from that status, if he or she has permanent impairments regarding work, employment, career development and employability in general. There are two ways to acquire a legal disability status (depending on the length of employment): through ZPIZ and the Pension and Disability Insurance Act for insured persons or through the ESS and the ZZRZI for unemployed persons with disability.
The legislation addresses the issue of employment of persons with disability indirectly, as it covers much broader topics of social protection as well. Under the Pension and Disability Insurance Act, the following programmes/schemes to promote the employment of persons with disability are listed (several of them covered in Chapter 1): disability allowance, compensation for disability, vocational rehabilitation, transfer to another workplace and part-time work, workplace adaptation, on-the-job training, formal and non-formal education. Under the Vocational Rehabilitation and Employment of Persons with Disability Act, the following programmes/schemes/rights are available: vocational rehabilitation, supported employment, wage subsidies, workplace adaptation, exemptions from tax and social security contribution, the award for exceeding the quota, employment in companies that are adapted for employment persons with disabilities.
Given the long-term nature of sickness leave, employment of persons with disability and health problems should also be part of the Health Care and Health Insurance Act, which regulates sickness insurance, but that is not the case. Although employers contribute the funds for occupational diseases and injuries to the health insurance, these funds are not available to rehabilitate workers on sickness leave.
The main responsible institutions for implementing vocational rehabilitation measures fall under the Ministry of Labour, Family, Social Affairs and Equal Opportunities. These are the Employment Service of Slovenia (ESS), the Pension and Disability Insurance Institute of Slovenia (ZPIZ), the Public Guarantee, Maintenance and Disability Fund of the Republic of Slovenia, the Slovenian Association of Vocational Rehabilitation Providers, the various private vocational rehabilitation providers, and the Development Centre for Vocational Rehabilitation at the University Rehabilitation Institute.
Vertical co-operation of each institution with the ministry is now common practice but horizontal co-operation among individual institutions is lacking. As a result, different programmes are not well connected and it is not possible or very difficult to switch from one to another, even in situations where this would be a good solution. For instance, employment rehabilitation and vocational rehabilitation do not offer the same services, so it would be sometimes reasonable for an individual to switch from one programme to another, but that is not possible. Multi-sectoral co-operation (e.g. between ZZZS and ZPIZ) is particularly problematic, which reflects, among others, the long duration of the various procedures.
5.1.2. Psychosocial programmes
Besides programmes for promoting employment of people with disability, there are other psychosocial programmes aimed at promoting inclusion and development in other life areas, not directly aimed at promoting employment. The significance of those programmes lies in raising self-esteem and quality of life in general, which can influence employment possibilities. This includes various programmes for persons with mental health problems, defined in the Mental Health Act (Zakon o duševnem zdravju) and the Resolution on the National Mental Health Programme (MIRA) 2018-28. MIRA is the first strategic document in the Republic of Slovenia that comprehensively addresses and regulates the field of mental health.
The programme connects existing and adds new services and structures to respond to people’s mental health needs, with focus on strengthening mental health and preventing and comprehensively treating mental disorders. To this end, it connects the services of all responsible sectors, i.e. health, social care, education and training. The goal of the programme is to establish a good supportive environment in all areas of mental health care, and to bring services closer to users and encourage them to seek help early, thus reducing institutionalisation in the field of mental health.
5.1.3. Employed persons with disability
Legislation promotes the employment of persons with disability through various measures. For person with disability who have a job, the legislation obliges employers to an active role in solving problems in relation to employment, to reduce the risk of unemployment. However, dismissal is possible for an employer who no longer has a suitable job to offer (see below for more details).
More problems arise in the employment of people with disability in small businesses, with fewer employment possibilities due to working conditions and greater demands. In particular, there is a lack of professional support for small businesses and a less developed support network, while there are no differences in financial incentives for large or small businesses. In smaller companies, there are no professionals employed to advise the employer on the employment of people with disability. There are also fewer options for reassignment in smaller businesses in the event a person is no longer able to perform his/her job due to a disability.
There is a need to establish special centres or information points, which provide employment support for people with disability and their employers. In such centres or contact points, employers and insured persons should receive all the information on the possibilities for returning to work, regardless of the legal basis of their rights. The proposal for the organisation of such support will be one of the main outcomes of the Early Vocational Rehabilitation and Return-to-Work Process Project (see Box 5.1).
Another measure to promote employment of persons with disability is the quota system, regulated in the Vocational Rehabilitation and Employment of Persons with Disabilities Act. Employers in both public and private sector organisations employing over 20 employees have an obligation to hire a certain share of workers with disability. However, little information is available about quota fulfilment.
Employers who hire persons with disability with reduced work capacity can receive compensation from the government for the possible loss in productivity. A wage subsidy to compensate the loss in productivity is a right to which a person with disability is entitled.
Significant challenges remain in increasing employment of persons with disability. First, stigma and bias against disability prevail in workplaces and among employers, who have insufficient knowledge and information regarding employment of persons with disability and their work ability. Second, there is a shortage of adapted workplaces. Third, the quota system stipulates a quota between 2% to 6%, depending on the company’s activity. The low lower boundary of 2% applicable in many sectors is unjustified and the quota to be increased in the affected sectors. This includes: wholesale and retail, repair of motor vehicles and motorcycles, accommodation and food service activities, information and communication, financial and insurance activities, professional, scientific and technical activities, public administration and defence, compulsory social security, arts, entertainment and recreation, and other service activities.
The Pension and Disability Insurance Act (ZPIZ-2) grants the right to vocational rehabilitation, in addition to the rights to compensation for disability, to transfer to another workplace, to part-time work, the rights to other allowances under disability insurance, and a right to reimbursement of travel expenses.
Recall that the precondition for acquiring any rights under the Pension and Disability Insurance Act is that the treatment and the process of medical rehabilitation is completed. The process of vocational rehabilitation as a right under this Act cannot start if the person is still waiting for surgery or other therapeutic interventions, or is involved in any form of medical rehabilitation. Due to waiting times for therapeutic interventions and rehabilitation and due to the course of the treatment itself, vocational rehabilitation is postponed even though the insured person would be able to start the process. The end of the treatment has to be declared even before an adjustment of the workplace or work environment or before a technical adaptation of the workplace. Therefore, the person cannot test the adjustment in the given circumstances and before the actual return to work happens. This is also a problem for the unemployed, because they cannot acquire the right to workplace adjustment when they get employed.
Recall also that the number of disability applicants engaging in vocational rehabilitation remains stubbornly low. Figure 3.6 in Chapter 3 showed that in 2019, 141 disability claimants participated in vocational rehabilitation, about 40% of these initially referred to vocational rehabilitation. This figure is not very optimistic on the current capacity of the system to engage disability claimants in return-to-work activities.
The 2016 White Paper on Pensions posits that a potential reason for the low take-up of vocational rehabilitation may be its poor outcomes (MDDSZ, 2016[1]). Presenting qualitative evaluations, the White Paper suggests that employers too often are not willing to maintain an employment relationship with disability claimants undergoing rehabilitation. This is the result of a lack of co-operation between employers, employees and professional rehabilitation workers. Moreover, the duration of vocational rehabilitation tends to be long, further worsening the employability of the participants. Finally, participants may fear having to reimburse the costs of vocational rehabilitation in case of unsuccessful completion.
Vocational rehabilitation most often takes the form of education or training, although adjustments of the workplace and practical work are slowly gaining importance over time. Table 5.1 shows that in 45% of the cases, vocational rehabilitation involved further education, and in 35% short-term training or education. The weight of education is declining over time, to the advantage of other forms of vocational rehabilitation such as adjustment of the workplace.
Vocational rehabilitation is available almost exclusively to young workers, in line with the strong emphasis of the programme on education and training. Figure 5.1 shows that very few beneficiaries over age 45 ever engage in vocational rehabilitation. The bulk of claimants are under age 40, apparently the age when participating in training and education (to improve employment opportunities) is considered a meaningful step, a view shared by the employers contacted during the OECD missions. Note the very similar age distribution with claimants of temporary benefits, in line with the previous evidence presented on the characteristics of the claimants of both programmes.
Source: OECD calculations based on Pension and Disability Insurance Institute of Slovenia (ZPIZ) data www.zpiz.si.
Other than the share of claimants ultimately engaging in vocational rehabilitation, there is no information to assess the effectiveness of vocational rehabilitation services. Data on the outcomes of vocational rehabilitation are not available, which makes impossible any analysis of the programmes. The OECD team has encountered substantial reservations to sharing data on vocational rehabilitation, let alone linking these data with other administrative records to analyse their effectiveness. There are also no impact evaluations of the programmes available, nor any plans to conduct them.
5.3.1. Employment Rehabilitation and Employment of Persons with Disabilities Act
The previous chapter concluded that the ESS is putting significant emphasis on identifying health barriers to employment. The ESS has several tools in place to profile registered jobseekers, including a medical assessment to help caseworkers make informed decisions in cases of suspected health barriers to employment. Another tool to identify health barriers to employment are the services under the ZZRZI act. While the goal of this act is to regulate employment rehabilitation, the first step of the rehabilitation process is an assessment under the Standards for Vocational Rehabilitation Services,2 and an opinion on the eligibility for the disability status and the right to vocational rehabilitation services. As the data show, a very relevant part of the work of the ESS through this act is to grant a legal disability status.
The ESS decides on entitlement for employment rehabilitation with help of rehabilitation providers. Rehabilitation providers send an opinion to the ESS, where the Rehabilitation Commission decides upon an assessment of the opinion of the provider. The ESS has to issue a decision on the status of a person with disability and the right to employment rehabilitation, before referral to employment rehabilitation. The ESS rehabilitation counsellor in co-operation with the person with disability defines the plan of rehabilitation with a set of appropriate services.
Employment rehabilitation services aim to prepare persons with disability for a new job. Service users gain better insight into their abilities and strengths, get to know their limits and become aware of the available support for performing their work. They can redefine their career goals and gain an understanding of the knowledge, skills, and experience required for a job. Services target the development of social skills as well as work-related skills. The interdisciplinary rehabilitation team can provide assistance as required including psychosocial support, vocational guidance and job-search assistance. Successful employment rehabilitation requires the co-operation of employers and can include workplace and work environment analysis and adjustments, on-the-job training, and professional support in the workplace.
Two pieces of legislation for one type of intervention
Two parallel legislations on rehabilitation are reflective of the disconnection of the system. While, effectively, rehabilitation services offered under ZPIZ-2 and ZZRZI are quite similar, there is not a single act serving as umbrella legislation for the employment of persons with disabilities. The government has adopted several documents to promote employment of persons with disability, regardless of the type of disability, but divided the support by individual organisational units, with a lack of co-operation among them. While the legislation under the ZZRZI is coherent and compatible, there is no link to the ZPIZ-2 in the field of vocational rehabilitation.
The legislation brings a dichotomy in the services and treatment offered to those eligible for disability insurance and those not eligible. There is a gap in the national legislation between the employment needs of persons with reduced work capacity and legal provisions on their professional (re)integration, between ZPIZ-2 and ZZRZI:
Psychosocial services and supported employment services are recognised and enabled only for persons with disability included in the rehabilitation process under the ZZRZI;
While the ZZRZI provides a wider range of services, it does not provide payment for education, which is possible in principle for all unemployed persons through the Active Labour Market Programmes offered by the ESS but depends on the annual budget;
On the contrary, ZPIZ-2 cover education services while it otherwise offers a smaller range of rights regarding employment (work place adaptation, formal and informal education, training for new profession), excluding psychosocial and supported employment services.
A key difference between vocational rehabilitation (ZPIZ) and employment rehabilitation (ZZRZI) is the role played by employers. Employers play a major role in the process of vocational rehabilitation as specified under ZPIZ-2: the purpose of rehabilitation is to find a job with the same employer, and employers may prevent their employees from engaging in vocational rehabilitation if they cannot offer a suitable job under any circumstances. Employment rehabilitation under the ZZRZI targets unemployed persons with disability, with the aim to help them in finding a new job that accommodates their disability.
Employment rehabilitation providers
A network of rehabilitation providers offers employment rehabilitation services. This network consists of 14 providers that operate throughout the country. One of them is a public institution while all others are private organisations with public service concession. Providers unite in the Slovenian Association of Vocational Rehabilitation Providers, which operates on the national level. Each service provider within the network of providers operates on the regional and local level to respect the principle of equal access.
All rehabilitation providers provide the same services. They must provide all vocational rehabilitation services in accordance with the standards. The law also determines the composition of the expert teams which include different professionals, including occupational therapists, psychologists, social workers and other profiles of social sciences, humanities (e.g. pedagogues) and technical fields (e.g. rehabilitation technologists). A specialist in occupational, traffic and sports medicine is required. Vocational rehabilitation services for the blind and partially sighted are provided only by URI-Soča and for the deaf and hard of hearing only by Racio. They both provide services throughout Slovenia as a mobile team.
Every vocational rehabilitation provider is obliged to develop a network of employers. This provides a set of possibilities to reach the most optimal conditions for specific workplaces or selected professions, with the aim to ensure the improvement of employment opportunities for persons with disability. The network includes regular employers and employers who employ under special conditions (employment centres and companies specialised in employing persons with disability).3 In the current network of active employers, as in previous years, most companies were from the regular work environment, followed by employment centres and companies specialised in employing persons with disability. Co-operation with associations, institutes and social enterprises is not negligible either.
Long waiting times of providers is an issue, even after completion of the assessment of disability. As discussed above, medical assessments to identify health barriers to employment typically happen long after the start of unemployment spells. This is the result of long waiting periods at many vocational rehabilitation providers, varying greatly across providers (between one week and 15 months). The long waiting time between the decision on acquired disability rights and the referral to vocational rehabilitation services is problematic for many, as both motivation and employability drop over time.
Quality control
The Development Centre for Vocational Rehabilitation at the University Rehabilitation Institute is responsible for drawing up quality standards in the area of vocational rehabilitation, using European Quality in Social Services (EQUASS) standards. EQUASS aims to enhance the social service sector by engaging service providers in quality, continuous improvement, learning, and development, to guarantee service users high the quality of services throughout Europe. The EQUASS standards comprises ten quality principles (Leadership, Staff, Rights, Ethics, Partnership, Participation, Person-centred approach, Comprehensiveness, Result Orientation, Continuous improvement), broken down into detailed quality criteria (in total, about 50 criteria). Specific performance indicators measure the performance according to the quality criteria. Those principles, criteria, and indicators must be taken into account while implementing the EQUASS standards and striving for valid and relevant results for EQUASS Assurance or EQUASS Excellence recognition by the European Quality for Social Services.
The network of vocational rehabilitation providers in Slovenia follows EQUASS standards since 2010 (at URI-Soča, since 2007). The Ministry of Labour, Family, Social Affairs and Equal Opportunities strongly supports the EQUASS quality standards. Note that vocational rehabilitation providers in Slovenia use EQUASS standards also for the services provided under the Pension and Disability Insurance Act.
Outcomes of employment rehabilitation
Around 1900 jobseekers are included in employment rehabilitation every year (Table 5.2). This number, which has remained more or less constant during the past decade, includes jobseekers with disability regardless of the type of their disability (including mental health, physical, intellectual, and/or sensory impairments). According to the provisions of the network of rehabilitation providers, the annual norm is around 1980 treated persons per year, or between 100 and 120 rehabilitees per rehabilitation team, an average of 110 persons per professional team (referred by the ESS).
There is substantial regional variation in the take up rate of employment rehabilitation, compared to the number of unemployed with disability. Across Slovenia, 15% of jobseekers identified as having a recognised disability are included in employment rehabilitation. This share ranges from as low as 8% of these jobseekers in Sevnica to 22% in Velenje and Nova Gorica. The number of jobseekers participating in employment rehabilitation over the total number of jobseekers ranges from 2-5%, not entirely in line with the shares of participation over identified jobseekers with disability (Table 5.2).
The large majority of assessments issued by the Rehabilitation Committee classify employment rehabilitation participants as unemployable. Participants who do not transition to the open labour market are classified by the Rehabilitation Committee according to their degree of employability. Table 5.2 shows that, nationally, 69% of participants are assessed unemployable after completion of the vocational rehabilitation programme, 17% could work in protected or sheltered employment, and 14% in supported regular employment. There is large variation in these shares across ESS regions, in line with the availability of establishments of supported and/or protected employment. For instance, in Novo Mesto, 62% of participants are employable under supported employment, while this share is 4% in Maribor and Murska Sobota. The share of protected employment varies a little less across regions, still ranging from 30% in Ljubljana to 4% in Trbovlje and Velenje. Underdeveloped supported and protected employment systems result in high shares of assessments as “unemployable”, which in turn prevents these jobseekers from being further activated.
About 27% of the participants in employment rehabilitation transition to any form of employment (Table 5.3). The employability assessment of the Rehabilitation Commission provides only a partial picture of the outcomes of employment rehabilitation. More interesting is how many jobseekers actually transition to employment after participating in employment rehabilitation. Data show that the transition rate is largest for jobseekers with a legal disability status (32%), followed by jobseekers obtaining a disability status through the ZZRZI (30%). Partial disability beneficiaries are benefitting the least from employment rehabilitation. The high rate of transition to employment for holders of a legal disability status may be surprising at first, as these persons usually have congenital and more severe disabilities. Given that there is no obligation for holders of a legal disability status to register with the ESS, those observed in this analysis are possibly a selected sample, with a particular interest in and capacity to work. The poor performance of partial ZPIZ beneficiaries partly is a result of the structure of the employment rehabilitation system for ZPIZ recipients, as described in more detail below. Until the 2021 amendment of the ZZRZI, recipients of partial ZPIZ benefits did not receive remuneration for their work when working through the system of employment rehabilitation. The 2021 amendment removed this dichotomy, allowing recipients of partial ZPIZ benefits to receive financial incentives, incentivising ZPIZ recipients to fully engage with, and benefit from, employment rehabilitation.
The share of jobseekers still unemployed after participating in employment rehabilitation increases with the duration of unemployment before entry in the programme (Table 5.4). Of those jobseekers entering employment rehabilitation in the second year of their unemployment spell, only 8% remain unemployed. This share increases to 16% for those entering in their third year, to 26% in the fourth, and to 50% for those participating after 5 years or more of unemployment. This dramatic increase with the length of unemployment calls for early vocational rehabilitation as a means to reduce unemployment. In this context, it is worth emphasising that participating in the first year of unemployment is not happening, because of both the long waiting times at vocational rehabilitation providers, and the large caseloads for ESS caseworkers: early activation, at present, means intervening in the second year of unemployment.
Vocational rehabilitation providers note the increasing complexity of their cases, which sometimes have to go through Social Inclusion Programmes first. The employment of people with mental health problems, the increase in demands of employers and the increase in complexity of health problems are among the biggest problems for employment rehabilitation. Unemployable persons with disability have the right to participate in the Social Inclusion Programme funded by Ministry of Labour, Family, Social Affairs and Equal Opportunities. These are special programmes designed to support and maintain the working abilities of persons with disability, implemented by special providers selected via a public tender for a period of four years. It is possible to transfer from the Social Inclusion Programme to employment, but such transfers are an exception.
5.3.2. Labour market programmes for jobseekers with disability
In addition to participating in employment rehabilitation, persons with disability can participate in Active Labour Market Programmes (ALMPs), non-specifically tailored for persons with disability. These programmes are aimed at all unemployed people and their availability depends on the resources available. The choice of participants to these programmes does not depend on their health conditions. ALMPs can take the form of training and education, employment subsidies, job creation measures, self-employment subsidies, among many others.
ZPIZ beneficiaries are overrepresented among participants in job creation programmes, in line with the greater employability challenges they face (Table 5.5). Public works programmes aim at stimulating and developing new workplaces or preserving current ones, and developing the working ability of unemployed people. These programmes are organised to conduct social, educational, cultural, environmental, municipal, agricultural and other measures (Južnik Rotar, 2011[2]). These programmes target jobseekers facing health barriers to employment compounded by social exclusion and other social challenges.
The effectiveness of ALMPs is lower for ZPIZ recipients than for other jobseekers. This is not surprising, as jobseekers receiving ZPIZ benefits have a lower employability than the average jobseeker. Despite participating in ALMPs, lacking labour demand may hinder a transition to the open labour market. Figure 5.2 shows the share of ALMP participants that do not transition to employment after participating in ALMPs, by duration since programme participation. A much smaller share of jobseekers receiving ZPIZ benefits transitions to employment than for the average jobseeker. Comparing ZPIZ and FSA recipients, the difference is less striking, however. During the first month after participating in an ALMP, a very similar share of ZPIZ recipients and FSA recipients among jobseekers transition to employment. For ZPIZ recipients, the transition to employment plateaus quickly (see the kink in the curve after the first month after programme completion), while employment transitions mildly continue for FSA jobseekers.
ALMP: Active Labour Market Programme, ZPIZ: Pension and Disability Insurance Institute of Slovenia.
Note: The share of transitions to employment is constructed from raw data, mimicking a survival probability analysis. Prior to being on an ALMP, no participant was employed (i.e. the share that has not transitioned to employment=100%). As transitions to employment occur, this share is recalculated, by time since participating in an ALMP, taking into account the persons who have not transitioned to employment.
Source: OECD calculations based on European Social Survey, www.europeansocialsurvey.org/data/.
ZPIZ beneficiaries participate in ALMPs much later than the average jobseeker, in line with a push to have these beneficiaries find a job independently in the open labour market. Table 5.6 illustrates that 53% of all jobseekers participate in ALMPs in the first five months of an unemployment spell. This figure drops to around one in four for jobseekers receiving FSA or ZPIZ benefits, possibly due to the stronger activation requirements for unemployment benefit recipients. For FSA recipients, contrary to regular jobseekers, participation in ALMPs is largely independent of the duration of unemployment. The most striking finding for ZPIZ recipients among jobseekers is the very high share of them (48%) participating in ALMPs only after having been unemployed for at least two years. These data are in line with ESS experts’ views that recipients of ZPIZ benefits do not have sufficient incentives to participate in ALMPs. This figure is even higher when looking at participation in employment rehabilitation: 80% of jobseekers receiving ZPIZ benefits enter employment rehabilitation only after two years of unemployment. According to ESS experts, this is the result of a practice expecting from beneficiaries of partial disability benefits to find a job by themselves in the open labour market.
ALMPs are most effective in returning people to work early in the unemployment spell. Early help is more likely to have an impact on subsequent employment. The effectiveness of ALMPs decreases as the pre-participation unemployment spell increases. Jobseekers participating in ALMPs in the first five months of their unemployment spell are twice as likely to find employment one month after completion of the programme as jobseekers with 24+ months of unemployment (Figure 5.3). This strongly aligns with findings from research which has established that early intervention is more effective than late intervention (Card, Kluve and Weber, 2010[3]). The policy recommendations from this finding are clear: activation and ALMP participation should kick in as early as possible in the unemployment spell.
ALMP: Active Labour Market Programme. FSA: Financial Social Assistance. ZPIZ: Pension and Disability Insurance Institute of Slovenia.
Note: The survival function is calculated using a Cox proportional hazard model including the type of main source of income support (FSA, ZPIZ, and other), the months of unemployment before participation in ALMP (0-5 months, 6-12 months, 13-23 months, 24 and more), and an interaction between the two. Early intervention is the survival function for jobseekers participating in ALMPs within the first five months of unemployment spell, while late intervention is that for jobseekers participating after 24 months.
Source: OECD calculations based on European Social Survey, www.europeansocialsurvey.org/data/.
The low effectiveness of ALMPs for ZPIZ recipients forces rethinking the current process. Figure 5.2 shows that ZPIZ recipients respond less to ALMPs than the average jobseeker. While this may be because ZPIZ recipients have a lower degree of employability, it may also partly be a consequence of their late activation.
5.3.3. Comparison of the effectiveness of the different types of interventions
One in four partial ZPIZ beneficiaries participate in an ESS programme, in one of three ways: through a medical assessment, employment rehabilitation, or ALMP participation. ZPIZ recipients participating in ALMPs have higher relative educational attainment than those included in medical assessments, but have a similar age distribution (Table 5.7). The age distribution of participants is different from that of participants in employment rehabilitation, who tend to be younger.
ZPIZ beneficiaries seeking work more often enter employment after participating in ALMPs than after employment rehabilitation. Employment rehabilitation facilitates a transition to work less often than the participation in employment rehabilitation, with significant differences by age in the use of the different types of interventions (Figure 5.4). Inclusions into medical assessment rarely are a followed directly by a switch into employment. There are several potential explanations for these differences in age-specific patterns in the take-up of services offered by the ESS:
There are compositional differences in participants to different types of interventions, as seen in Table 5.7. Notably, ALMP participants have a relatively higher skill level, increasing their chances in the labour market. This would bias the results into showing a relatively higher effectiveness of ALMPs over employment rehabilitation and medical assessment.
The system is organised such that ZPIZ recipients are included in medical assessments and employment rehabilitation as a last resort, only if they do not manage to find a job in the open labour market. The nature of the health barriers of those included in medical assessment and employment rehabilitation is thus probably more severe than that of recipients included in ALMPs.
As a result, while it is true that participation in ALMPs happens quite late for ZPIZ recipients, inclusion in medical assessment happens even later. Almost 80% of inclusions to medical assessment take place after 24 months of unemployment (compared to 48% for ALMPs) and only 3% are included in medical assessments in the first five months of unemployment (compared to 26% for ALMPs). In line with the evidence that early intervention is key, these differences in timing of intervention could be driving part of the results.
ALMP: Active Labour Market Programme. ZPIZ: Pension and Disability Insurance Institute of Slovenia.
Note: Shares are calculated as the outflows from unemployment to employment in 2019 by intervention type over the total outflow to employment of all partial ZPIZ beneficiaries in 2019. Explained exits are the sum of all exits by intervention type over the total outflow: a value lower than 100 indicates that not all persons exiting unemployment can be traced back. For medical assessment and ALMP programmes, outflows to employment are the sum of all outflows for up to a year after participation, without taking into account re-entry to unemployment.
Source: OECD calculations based on European Social Survey, ww.europeansocialsurvey.org/data/.
To assess the relative effectiveness of one intervention over the other, it is necessary to conduct a proper impact evaluation of the different programmes, either making use of individual-level administrative data in a regression-based analysis, or by evaluating the programmes in a randomised controlled trial. At present, there is no more in-depth evidence available than the one provided in this report.
The possibility to vocational rehabilitation during long-term sick leave is available only for those insured persons included in medical rehabilitation in URI-Soča. Vocational rehabilitation at URI-Soča is an integral part of ZZZS-funded medical rehabilitation, not mentioned specifically in the legislation. Insured workers are on sickness leave at the time of treatment, and referred to the programme by GPs and other medical specialists. The outcome of this programme can be a gradual return to work or a proposal for the assessment of working capacity at the Pension and Disability Insurance Institute.
A rehabilitation team, from the Vocational Rehabilitation Centre (CPR), assesses the compatibility of the remaining functions of injured/ill people with the burden in their workplaces. The rehabilitation team consists of a doctor, a specialist in occupational, traffic and sport medicine, a psychologist, a specialist in clinical psychology, an occupational therapist, a social worker, a rehabilitation technologist and other experts, such as inclusive teaching methods in the treatment of blind and partially sighted people with disabilities. This set up is similar to the teams set up in other institutions providing vocational rehabilitation. Part of the work of the expert team is to meet with employers, and present them their employees’ functional limitations and suggest appropriate work adjustments.
Those undergoing vocational rehabilitation at the CPR represent a small fraction of long-term sickness claimants. In 2020, 475 employees were included in the CPR for vocational rehabilitation (Table 5.8); of these, 84 were in a hospital in Ljubljana. Hospitalizations are available to those insured workers who cannot come for treatment on a daily basis due to a health impairment or the distance to their place of residence. This is only a small share of potential people, taking into account that in 2019 there were more than 8 000 people on sick leave for more than one year in Slovenia. Therefore, the extension of professional activities to the primary level of health care would be necessary.
Almost two-thirds of CPR participants suffer from mental, musculoskeletal or cardiovascular diseases (Table 5.8). However, there are big differences in the structure of diagnoses across the centres of Maribor and Ljubljana.4 The main reason is that most of the people referred for vocational rehabilitation in Ljubljana are previously included in medical rehabilitation at URI-Soča, so people with cardiovascular diseases (stroke condition) predominate. In Maribor, many people come with a referral from their GP and mental health diseases predominate.
Almost half of the participants in CPR with mental health diseases are employable, either directly or with workplace adaptations (Table 5.9). While these outcomes are not fully comparable to the decisions issued after participation in employment rehabilitation under the ZZRZI, the employment outlook for CPR participants is much more positive. There are several reasons that could be causing this, starting with differences in the severity of disability and type of diagnosis, but also the timing of intervention. CPR participants are typically on sickness leave for only several months and less than a year before starting treatment. ZPIZ claimants, on the other hand, have to complete medical treatment before participating in any vocational rehabilitation. The much earlier intervention could be instrumental in the success of vocational rehabilitation to promote the employment of persons with disability. The need for early intervention is the objective behind the current ESF-funded project with the Ministry of Labour, Family, Social Affairs and Equal Opportunities (see Box 5.1).
Most participants not returning to employment make a claim to ZPIZ or ESS under the Vocational Rehabilitation and Employment of Persons with Disabilities Act (ZZRZI). One in five CPR participants apply for a ZPIZ disability pension, considered unemployable. The remaining 27.8% transfer to the ESS, to receive support in finding employment. Very few people move on to further education. This analysis shows that the treatment usually shows the need for long-term support and co-operation across institutions providing vocational rehabilitation, and in particular, with the ESS.
ESF-Funded project on early vocational rehabilitation
To tackle the issues regarding the long duration of sick leaves, the low percentage of insured people that assert their right to vocational rehabilitation, and the lack of co-operation of the key institutions in the return-to-work process, the Ministry of Labour, Family, Social Affairs and Equal Opportunities proposed a project to improve the return-to-work process in Slovenia.
The Early Vocational Rehabilitation in the Return-to-Work Process Project started in May 2020 and running until December 2022. The project aims to seek solutions, which will serve as the basis for further implementations of systemic changes in practice. The project is managed by URI-Soča in co-operation with various stakeholders, including the Ministry of Labour, Family, Social Affairs and Equal Opportunities, the Ministry of Health, the Pension and Disability Insurance Institute of Slovenia, the Health Insurance Institute of Slovenia, providers of vocational rehabilitation services, occupational, traffic and sports medicine specialists, employers and insured persons. The project is co-financed by the Republic of Slovenia and the European Union, through the European Social Fund.
The activities of the Early Vocational Rehabilitation in the Return-to-Work Process project focus on solving employment problems of persons with reduced work capacity. The purpose of the project is to reform the current model of vocational rehabilitation into a comprehensive early vocational rehabilitation in the return-to-work process, with focus on promoting co-operation between all the participating stakeholders in the return-to-work process. The project will address system deficiencies, such as lack of connection between medical and vocational rehabilitation, differences in the two vocational rehabilitation programmes, and lack of comprehensive information on both vocational rehabilitation and the return-to-work process. Based on the results of the pilot implementation of the new vocational rehabilitation model, the project will propose new systemic solutions. The project results will thus help preventing early exit from the labour market, especially of persons who had been absent from work long-term due to illness or disability.
Source: University Rehabilitation Institute Republic of Slovenia (URI-Soča) data www.ir-rs.si/.
Among participants with mental health conditions, there are notable differences in the outcomes of vocational rehabilitation. In the case of organic mental disorders, the proposal for retirement or unemployment is most common; in schizophrenia, personality disorders and mental retardation, the most common suggestion is employment rehabilitation under the ZZRZI and in personality disorders also the ability to work full-time with restrictions. Ability to work full-time but with restrictions is also the most common suggestion in mood and neurotic disorders.
There has been a gradual shift in the role of the CPR, from being the basis for assessment at ZPIZ to providing complete return-to-work services. In 2010, a targeted study showed that the ZPIZ board fully endorses 64% of CPR opinions and summarises them in its own opinion. In recent years, CPR has completely shifted to the return-to-work process and is trying to introduce good practice in this area.
5.5.1. Employers have unusual roles in the Slovenian system
Employers are fully responsible for ensuring health and safety at work. They have to involve occupational medicine specialists and safety at work engineers in certain tasks, but the ultimate responsibility remains entirely with the employer.
The role of employers during sick leave
During each sick leave, the employer has to pay the employee’s wage for 30 working days. After this period, the Health Insurance Institute of Slovenia takes over continued wage payments. In Slovenia, the incidence of sick leave in 2019 was 4.6%, of which 2.1% was at the expense of employers and 2.5% at the expense of the ZZZS. Employers have no special obligation to maintain contact with a worker who is on sick leave. There are protocols on who the worker must inform that he is absent from work (usually the immediate superior or the human resources department). In the past, employees themselves had to deliver a sickness certificate from their GP to the company but since 2020, employers receive information on approved sick leave online. It thus now depends on the level of communication within the company, if the employee reports a sickness absence at all.
When the payment of compensation transfers to the ZZZS, the employer also receives the decision of the appointed doctor. If the employee appeals against the decision of the ZZZS not to extend the sick leave and corresponding payments, there are significant delays in issuing new decisions. In that case, neither the worker nor the employer know whether the worker should come to work or whether sick leave continues. The situation is often resolved by using annual leave during the appeals process.
When a worker is on sick leave and his compensation is borne by the ZZZS, the employer has no obligations to him, he only has to pay him a holiday pay. Therefore, employers often instruct a worker to return to work only when they are completely healthy. During this time, they usually delegate work to other workers or hire new workers, and these procedures are usually complicated and time-consuming. Workers are therefore also hesitant to return to work, knowing that they will have to work at 100% capacity immediately. An employer cannot obtain information from a GP during sick leave, and the involvement of physicians and occupational medicine specialists is not common. Employers monitor the level of sick leave through lost working hours, keep their own records and can monitor trends by months and years.
The employer can also obtain detailed information on sick leaves for his company from the National Institute of Public Health. They also prepare an analysis of the sick leave by groups of diagnoses (Chapter ICD X.) It is also possible to compare the amount of sick leave to economic activity in Slovenia, by sex and age groups. This information is chargeable to the employer. The employer can use such information to plan workplace health promotion and occupational safety and health measures.
The role of employers during disability assessment and in the vocational rehabilitation process
When an employee has permanent health impairments, the GP presents him to the ZPIZ disability board. In this application procedure, the ZPIZ invites the employer to fill in a special form called work documentation (DD1). It contains a very detailed description of the work process and the objects of work, and also assesses the burdens and harms in the workplace, especially those that could affect the health of the worker. This document invites the employer to propose the transfer of the employee to another suitable position, to exercise the right to vocational rehabilitation and to make other comments and suggestions that are important for consideration by the Disability Commission. Employers often put down, in this document, that they do not have a suitable position for an employee with health problems and suggest disability retirement. Occupational safety professionals and occupational medicine practitioners typically fill in the part that relates to possible health impairments and requirements for the job. In 2019, 575 insured persons and 226 employers responded to the ZPIZ’s invitation to the presentation of vocational rehabilitation. Among them, 332 insured persons expressed their interest in using the right to vocational rehabilitation and most of their employers supported them.
A ZPIZ expert prepares a preliminary opinion after reviewing the medical and work documentation. If vocational rehabilitation is a reasonable option for the employee (proposed by the employer, the GP, the insured person or the ZPIZ expert himself), as a right under the Act of ZPIZ, the ZPIZ invites the employer and the employee to a presentation of vocational rehabilitation options and procedures. At this occasion, the worker decides on his/her interest to participate in this process.
In the next step, the ZPIZ expert refers the employee to a vocational rehabilitation provider, who prepares a final report, which must clearly define the position on vocational rehabilitation, the method of implementation, the content and objectives, and the employer’s opinion on the proposed vocational rehabilitation. In this procedure, the contractor preparing the professional report must contact the employer, present the possibilities and purpose of vocational rehabilitation and report on subsequent decisions with the signed consent of the employer. The employer then signs a tripartite contract with his employee and ZPIZ on vocational rehabilitation.
During the vocational rehabilitation process, the employee receives salary compensation from the ZPIZ. The rehabilitee is entitled to compensation for the duration of the process, which in 2019 averaged at EUR 590. The length of the process depends on the form of vocational rehabilitation, the longest option being formal education that can last up to two years. The employer can state that, after completing vocational rehabilitation, he will not have a suitable job for the worker. After completion of the process, he may terminate the employment contract with the prior consent of the Commission of determination of the grounds for termination of the employment contract. The employer has no obligations during this time.
The employer is involved in the part of vocational rehabilitation connected to the work process, as he has the best understanding of the possibilities how to implement the necessary improvements in the workplace. This is particularly evident in the provision of adjustments of the workplace with technical aids for the performance of the same profession or work, in practical work in the relevant workplace, and for in-service training in the relevant workplace. The employer’s participation is also crucial in adjusting the work place or work resources needed to carry out vocational rehabilitation. When an employee receives training while working at a specific work place, the employer must offer another suitable job and present it to the senate of the disability commission with the form called work documentation (DD1).
Termination of a contract
It is possible to dismiss employees during sick leave, but it does not happen very often due to very complicated regulations. According to the Employment Relationships Act, for an employee whose employment contract has been terminated due to business reasons or incapacity and who is absent from work due to illness or injury, the employment relationship shall end on the day the employee returns to work, or should return to work, but no later than six months after the expiry of the notice period. The termination is therefore for either business reasons or incapacity.
When workers enter disability insurance and return to work, employers may terminate their employment contract if they are unable to provide employees with a suitable job in accordance with the restrictions imposed by the Disability Commission. An employer who has five or fewer employees can do this on their own. In the case of larger employers, the Commission must give an opinion on the possible termination of employment in order to determine the grounds for termination of the employment contract. During the course of vocational rehabilitation, when disability insurance covers the remuneration for the employee, the employer may not terminate the employee’s employment contract.
In almost three in four cases, the Disability Commission accepts the grounds for the termination of the employment contract (Table 5.10). The large majority or more than 90% of those laid off had a Category III disability status by ZPIZ classification. Most of those people should qualify for vocational rehabilitation. Proposals of ZPIZ Board of Examiners with significant restrictions, such as a ban on lifting heavy weights or no work in forced spinal postures, however, are often difficult for employers to meet.
5.5.2. Occupational physicians are underutilised in Slovenia
Legal developments and requirements
Occupational, traffic and sports medicine has a long tradition in Slovenia, dating back to the 18th century and the mercury mines of Idrija. In 1971, the Institute of Occupational Medicine was established. During this time, occupational medicine was part of the public health system. In the course of the social transition in 1991 and the Health Care and Health Insurance Act of the time, occupational medicine was annulled and reversible clinics were abolished. Occupational medicine was considered a remnant of the socialist system and corresponding activities transferred to the free market. Doctors specialising in occupational medicine concluded contracts with employers to perform their activity. Such an arrangement has remained to this day.
The Occupational Safety and Health Act of 1999 reintroduced occupational medicine activities into Slovenian legislation. With this law, last amended in 2011, the responsibility for occupational medicine came from the Ministry of Health to the Ministry of Labour, Family and Social Affairs. Today, there are approximately 190 occupational medicine specialists in Slovenia, most of them working directly with employers (only some work in the public health network). The director of the public institution in which these occupational doctors work conclude the contracts with employers.
An occupational physician is a health care provider in the field of occupational, transport and sports medicine entrusted by the employer to implement measures related to health at work. The tasks performed of an occupational doctor depends on the type of activity performed by the employer and the type and level of risk of accidents at work, occupational and work-related diseases. The majority of occupational physicians, while engaged in drafting the expert basis for the safety statement, are however mostly performing health examinations or health check-ups of workers. Employers shall provide workers with health examinations corresponding to their occupational health and safety risks.
There is quite a bit of ambiguity in this area, as occupational doctors also determine the general health condition of employees. The law also requires the occupational doctor to determine the special health requirements that a worker must meet in an individual workplace (without any clear guidance on the definition of special health requirements). In agreement with the Ministry of Labour, Family, Social Affair and Equal Opportunities, the Ministry of Health adopted an executive act, the Rules on Preventive Medical Examinations of Workers, which defines the types, scope and content of preventive medical examinations of workers and the manner and deadlines for performing these inspections. In practice, the employer determines the scope of preventive examinations on the proposal of an occupational doctor, in accordance with the risk assessment.
Everyday work in practice
Occupational physicians should inform workers on the risks related to the working environment, and the extent to which the work could lead to functional impairment, diseases or disability. In Slovenia, on the contrary, occupational physicians are not included in monitoring and analysing the situation related to occupational and work-related diseases – which fall under the remit of GPs. Sometimes occupational doctors draft reports for employers on findings resulting from analysis of the workers’ health status determined during health examinations. Such reports can contain proposals for the improvement of the work process aimed at complementing or upgrading the measures related to health at work.
Occupational physicians should also participate in the disability assessment, vocational rehabilitation process and advice on the selection of other appropriate work, but this is not usually the case. They are engaged in the preparation of the employer’s plan for first aid provision and participate in worker and employer training on general and specific first aid measures. In the execution of tasks, occupational doctors should co-operate with the worker’s GP and with disability and health insurance expert bodies, exchanging data on workers’ health status and helping to determine the justification of temporary or permanent absence from work and to assess the ability to work. Based on the worker’s prior written consent, the occupational doctor may obtain access to information on the worker’s health, treatment and rehabilitation from the worker’s GP. In turn, the occupational doctor shall communicate to the worker’s GP, on request, information on the worker’s workload and workplace requirements (which is necessary for the sickness and disability procedures).
Involvement in the return-to-work process
During sick leave, occupational physicians are not included in programmes or procedures to promote the worker’s return to work. In the sick-leave process, all services (treatment, rehabilitation, benefits) are under the responsibility of ZZZS. Occupational physicians are not part of the health insurance system, which thus cannot reimburse any of their services. Not involving occupational physicians in the return-to-work process is a missed opportunity but the consequence of the legislative changes in 1991, described above.
Occupational physicians, working in the field of worker health protection, are not included in the process of disability assessment and vocational rehabilitation in a systematic way. Their exclusion from the disability process is another missed opportunity. The only exception are occupational physicians who work in teams of vocational rehabilitation providers and in the Institute for Rehabilitation of the Republic of Slovenia (URI-Soča), Center for Vocational rehabilitation (CPR), unit Ljubljana and Maribor.
References
[3] Card, D., J. Kluve and A. Weber (2010), “Active Labour Market Policy Evaluations: A Meta‐Analysis”, The Economic Journal, Vol. 120/548, pp. F452-F477, https://doi.org/10.1111/j.1468-0297.2010.02387.x.
[2] Južnik Rotar, L. (2011), “Effectiveness of the Public Work Program in Slovenia”, Managing Global Transitions, Vol. 9/3.
[1] MDDSZ (2016), Bela knjiga o pokojninah (White Paper on Pension System Development), Lubjana, April, http://www.mddsz.gov.si/nc/si/medijsko_sredisce/novica/article/1939/7901/.
Notes
← 1. It is important to point out ambiguities in the terminology of vocational rehabilitation in Slovenia. The term vocational rehabilitation is officially only used for procedures regulated by the Pension and Disability Act, as it is precisely defined only in that act. In Slovenia, the term employment rehabilitation is used for the field of employment of persons according to the Vocational Rehabilitation and Employment of Persons with Disability Act. Internationally, the comparable term would also be vocational rehabilitation. There is no single term for the return-to-work processes that take place within the framework of medical rehabilitation at URI-Soča, although the experts use the term vocational rehabilitation.
← 2. The Standards for Vocational Rehabilitation Services define professional principles, the vocational rehabilitation process, its content, work methods and techniques, the expected results, as well as the fundamental professional and organisational conditions of service provision.
← 3. Such companies must have at least 40% of their workforce classified as a person with disability. Employment centres offer special form of employment under special conditions (sheltered employment).
← 4. Vocational rehabilitation has been part of rehabilitation activities in URI-Soča since its establishment in 1954. After the year 1984, it has been reorganised as an independent section in two regional units, in Ljubljana and Maribor.