Estonian health care
system in transition
The hospital point of
view
HOPE Study Tour No 4 for Senior
Hospital Professionals and Managers
21.10.2009. Tallinn, Estonia
Dr. Urmas Sule, CEO Estonian Hospital Association
and Foundation Pärnu Hospital
Dr. Teele Raiend, Certified quality manager, Foundation
Pärnu Hospital
We will…
• Talk about the key actors in health
care
• Major changes that have taken
place over the last 20 years
• How we got here where we are –
the reforms
• What has been and is the hospitals
role
• Quality management development
• And we expect for active discussion!
The Republic of Estonia
• Parliamentary republic, president elected for 5
years (Mr. Toomas Hendrik Ilves)
• Official language – Estonian
• Coastline – 3794 km with 1521 islands
• Total area – 45 227 km2
• Population – 1 370 000 (Estonians 65%,
Russians 28%, Ukrainians 3%, Belorussians
1%, Finns 1%, other 2%)
• Independent since 24.02.1918, occupied by the
Soviet Union 1940, regained the independence
on 20.08.1991. Member of the European Union
since May 1st 2004.
• We have been here since 6500 BC!
Basis for the Estonian
Health Care
• According to the Estonian Constitution, §10, social
justice in Estonia is a state-based right. This
means, that the state must provide the possibility to
receive certain vital services for its citizens, one of
which, according to the Constitution’s §28, is
everyone’s right to the protection of health.
• The right to the protection of health means the
state’s obligation to engage in both health
promotion and disease prevention as well as to
provide health services and benefits for persons.
As the state’s obligations are limited by its
economic situation, persons do not have the right of
claim, arising from the Constitution, against the
state in order to receive health services or benefits
to the extent not specified by other Acts.
Consequently, persons cannot demand the
provision of all health services. Neither can they
demand the provision of health services completely
free of charge and without a waiting period.
Key actors
• Financing – Estonian Health
Insurance Fund
• Government, Ministry of Social
affairs etc – legal basis, principles
and supervision
• Health care providers:
– The workforce
– Hospitals (and others)
• Legislative framework – marketorientation and obligations’regulation
The Soviet Heritage
• Centralized and state-controlled
• Over-capacitated provider network
– Strategic military network
– 120 hospitals with 18 000 beds (113 per 10
000)
• Health care free for everyone, the actual
costs of health care were rarely
considered
• Polyclinics
• Health promotion and prevention – nonexistent?!?
Reforms – the objectives
• Began in the end of 1980s
• Economic collapse, high inflation
and political clutter – the aim was:
– to improve the efficiency and quality
of health care system
– to meet the needs of a small country
and its population
• In conclusion, four major health
care reforms have taken place
Four major reforms
• Decentralization of health care
administration
• Organization of social health insurance
1992- 1994: A situation, were health
care services were equally available for
all people in Estonia and financing for
them was based on equal principles,
was created.
• Developing primary and public health
care
• Hospital network reorganization
Decentralization
1
• Decentralization of primary and
hospital care to local administrative
level, where individual or cooperating groups of municipalities
would provide both primary and
secondary care
• Elimination of special systems
• Separation of powers
Decentralization
2
• 1990: The Statute of the Ministry of Health Care was
endorsed
• 1993: The ministry of Social Affairs was formed
• 1994: Health Care Organization Law adopted,
according to which, the health care at local
government level was organized individually or
jointly by the municipality or town councils and the
municipal physician. This includes organization of
primary and secondary health care and control of
public health needs. Decentralization of the health
care services was stipulated.
• The County Physician Act was adopted, determining
its functions. County Physicians were put
responsible for the planning and control of health
care services at county level, health surveillance and
health protection of the population. Other levels that
were listed are municipality and town levels.
Financing
• January 1st 1992: Health Insurance Law
– From tax-based to insurance-based
– Regional Sick Funds
• A correlation between health care expenditure
and the national economy was established
• 1994 – 2002 updated, “second-wave
legislation” for health insurance
• 1997: the prices for medical services to be paid
by the clients themselves were regulated.
• 2000: The Estonian Health Insurance Fund Law
was adopted rearranging the institution of
health insurance with now only 1 central EHIF.
• 2002: new era (later).
Primary health care
• 1991: Tartu University Medical Faculty started respecialization courses for Family Practitioners
• 1993: Family Practitioners specialty was officially
recognized
• 1997: Decree of Minister of Social Affairs
– Selection of Family Practitioners for practices as private
practitioners in the regions
– Registration of population to them
– Developing a new financing and direct contracting
method with the Sick Fund for 1998
• The reorganization of primary health care services
was meant to constitute a key element of the health
reforms in Estonia planned by the government. The
central principle of this concept was that primary
care should be organized around the family
practitioner who should operate as the gatekeeper,
referring his patients to higher levels of care when
necessary. Another aim of reform was to establish
health promotion and prevention.
Hospital network
reorganization
• The reorganization of hospital network
took place in 1994 – 2001
– 1994: Health Care Organization Law
adopted
– 2001: Health Care Services Administration
Act adopted (enforced January 2002)
• The aim: to secure quality in health care,
thigh technology services should be
centralized to bigger hospitals and longterm care facilities should be created
• 2000: Hospital Master Plan
Case study – Pärnu
Hospital/ health care
services network
Health Care providers in
Pärnu 1994
•
•
•
•
•
•
•
•
Pärnu Hospital
Pärnu Dermatology Hospital
Pärnu Polyclinic
Pärnu Children’s Polyclinic
Pärnu Pulmonary Cabinet
Pärnu Ambulance
Pärnu Blood Center
Pärnu Health Inspection
Microbiology Laboratory
Pärnu Health Care
Reform 1996 - 1998
• Development of primary health
care services division – family
practitioners practices
• Joining practices of different
medical specialties under one
umbrella
•
•
•
•
Rights and obligations defined
Quality management
Introduction of patient centeredness
Assuring efficiency
Pärnu Health Care
Reform
• 1994: questions raised, discussions at the local
government
• 1994: Pärnu Hospital development plan (strategy)
• 1996: partial centralization of special secondary
medical services and separation from primary
health care
• 1998: final centralization of secondary medical
services
• 1999: creation of psychiatry clinic
• 2000: Foundation Pärnu Hospital
• 2002: joiner of Pärnu Ambulance to Pärnu Hospital
• 2002: new structure for Pärnu Hospital (quality
management enforced)
• 2004: joiner of blood center to Pärnu Hospital
• 2005: new hospital building
• 2005: joiner of microbiology laboratory to Pärnu
Hospital
New era
• 2001: Health Care Services
Administration Act adopted
(enforced January 2002)
– As Health Care System’s Constitution
– New definitions: from medical aid to
health care services, from doctors to
service providers.
– New legal bases: all providers work
under private law.
– Health Care Board was established
(full division of powers)
At the same time…
• 2002: The new law for Health Care
Insurance and Coverage was
adopted, with the idea to cut back
on health care expenditures in
order to be able to provide more
and better quality health care
• 1995;1999; : The Public Health
Law
• 1995; 2005: The Drug Law
The implementation of
the Hospital Master Plan
• Discussion
• Regionalism
• The Golden
Circle
The juridical clinch
• The Law of Obligations 2003
– Chapter “Health Care Services
rendering Contract”
– Contracting between purchaser
(patient) and provider (doctor)
• The Law on Patient Rights was
prepared already in 1993, but has
still not been properly discussed
nor approved until today.
Quality in Health Care
• 1997 Estonian Health Care Quality Policy
• 2002 (The Health Care Services Administration
Act): decrees on quality management and
accessibility; decree on documentation; work
standards; quality commission
– Licensing and certification
– Philosophy on self-regulation
– Independent nursing care
• 2002 Updated Quality Strategy
– Quality managers to hospitals
• 2003 (The Health Care Insurance and
Coverage Law): The Estonian Health Insurance
Fund only purchases quality services
The future
• Matching social- and medical
services
• E-health
• Economic problems have to be
solved in a sustainable way
• Patient safety?!
• How do we measure and define
quality services?
Estonian Hospital
Association
• representing members;
• developing health economics and quality
management;
• coordinating the activities of the Association and
exchange of experiences;
• compiling working groups to solve common
problems of the members;
• expressing opinions about health care
legislation and draft acts;
• collecting data about health care;
• counseling of members
• Social dialogue
Questions and answers
and discussion
Thank you!