Vitaliy Petrovskiy

PR and Media Coordinator

Health Care Reform In Estonia: What Is Useful For Ukraine

In the early years of independence, Estonian health care went through significant changes. First of all, the republic abolished the Ministry of Health, then the same happened to other government agencies. These measures ensured normal functioning of the entire health care system of the country without any intervention of its officials. In 1990, funding of the system was decentralized, it became financed with funds derived from proceeds of SHI.

The legal framework for health care reforming was reflected in the Health Insurance Act of 1991 and the law on the organization of medical services of 1994. In 2000, the Estonian Health Insurance Fund (EFMS) received a status of a self-governing public organization, followed by the law on contractual right that was passed in 2002, it set new legal relationship between patients and medical staff. Thus, the country has a new legal framework, and medical services are provided in accordance with European standards.

The key structure of the whole system is a sickness fund. Regardless of his/her income, every employee in Estonia has to transfer a medical cashier 13% of the wages, for self-employed – 20%. The state pays premiums for those who are temporarily on leave for child care, registered as unemployed for not more than 9 months and for people who care for the disabled. Since the end of 2002 voluntary insurance has been allowed for those who are left without health insurance. In case of voluntary insurance, premiums are 13% of the average wage in the country for the previous year.

The Council of the sickness fund determines the list of diseases and operations that are funded from the budget. All existing hospitals in Estonia are separate and independent, they buy equipment and drugs, are responsible for construction of additional buildings of hospitals, determine doctors’ salary and report on health care to local authorities. Family doctors are now something like entrepreneurs. They have to rent a room, enter into contracts with the sickness fund and local municipal agencies for services. Each family doctor has a list of permanent patients assigned to him territorially. The minimum number of people on this list is more than 1,200, while the maximum number of patients exceeds 2,000. In addition, patients may change their family doctor at any time.

The list of main services provided by family doctors is quite sufficient. It includes diagnostic procedures, treatment of common diseases, health consultations, disease prevention and health promotion.

Family doctors regulate further access of patients to most experts. In order to get treatment in hospitals, except emergency care, you need a referral from your family doctor, indicating the preliminary diagnosis. Without proper reference, you may refer to the following specialists: ophthalmologists, dermatologists, venereologists, gynecologists, psychiatrists and dentists. Traumatologists and surgeons deal with traumas.

The strategy of health care reforming in Estonia was based on the task of consolidating hospitals and concentrating available medical resources. In 1991 there were 120 hospitals for 1.3 million people in Estonia that met quite low Soviet standards. Now the number of hospitals is only 20, and the number of hospital beds was reduced from 18 to 4.5 thousand. However, quality of services has increased significantly. In only two post-Soviet decades average hospital stay was reduced from two weeks to five days in a residential treatment. The new health care organization in the country creates not only a new psychology of potential patients, but also contributes significantly to improvement of service quality. Estonians try to be sick less and pay more attention to preventing illnesses. After all, if a person loses work because of sickness, the sickness fund is able to support him/her for only two months, and contributions to the fund are lost.

As of now the average doctor’s salary in Estonia is about 2000 euros. It is actually 3-4 times smaller than in neighboring Nordic and other European countries, but still 10 times bigger than in Ukraine. The average life expectancy in Estonia is, according to the UN data, 76 years, a few years longer than at the times of the Soviet medicine.

The main distinction of the Estonian health care reform is that great functions are given to nursing and paramedical staff of hospitals. Hence, it is more qualified. In Estonia, intensive care nurses fully engage in taking care of patients, are capable of operating complex equipment and performing complete reanimation on their own if a patient was previously intubated. They have their own, nurse medical history and seals, so a nurse is a full range specialist with his/her duties and responsibilities. Normal pregnancies and childbirths are handled by midwives from beginning to end. They also represent junior medical staff. Of course, in case of doubt, doctors are turned to, but still nurses always have a sense of responsibility for the sick. To prove their qualifications, every 5 years nurses and doctors have to get 300 points, earned during this period at conferences, various schools and workshops (1 point = 1 hour). Once a year specialists develop a study plan choosing courses they are most interested in or those where it is necessary to improve their skills. Such training is paid for by hospitals.

Another important distinction is the behavior of patients’ relatives and friends in hospitals. Intensive care units are open for visits, so no one demands any gowns and masks, just shoes.
Estonia should be proud of its E-medicine and electronic system of governance. Every citizen of the country has a plastic card with a special chip, known as an ID-card. With this card you can look up interesting information on the Internet, obtain a certificate from an agency, sign electronic documents, make necessary payments, etc…. Since 2005, the country has had a unique medical database of all patient’s addresses to doctors, all previous diagnoses, prescriptions, test results, X-ray images and the results of CT-MRI-ultrasound examinations. ID cards are used to gain access to the database for doctors. Doctor appointments are made via Internet. Drug recipes are issued to patients electronically, so it is enough to submit your ID card at a pharmacy. Results of tests and studies appear in a medical history electronically, so everyone can print out relevant information. If something has not been entered into the database, the sickness fund does not pay for it. All invoicing is also electronic. Each workplace of doctors and nurses has a computer connected to the Internet.

Certainly, it is only natural that even this profound system has some cons. Many people complain about the existing 13% deduction from wages and short duration of a patient stay in a hospital. Nevertheless, everyone knows that commercialization has improved the quality of services. That’s why a new generation of Estonian doctors and nurses gets used to new technologies and is ready for even more radical changes in the health care system. According to Estonian press, the Government is not going to stop the process of reforming.

Thus, for the last 20 years, Estonia has managed to introduce obligatory health insurance, increase the quality and quantity of health services significantly and improve socio-demographic indicators such as life expectancy and infant mortality throughout the country. Currently, according to authoritative experts of the international organization Health Consumer Powerhouse HCP, who analyzed medical care and services in the EU, Estonian health care system is among the best in Europe. In 6 major categories that are based on 34 indicators, Estonia has a high score of 669 out of 1000 possible, allowing the country to be in the 10th spot in the overall ranking. Estonia won in the Bang for the Buck category for the best value for money, considering GDP.