UrmasEstonian Health Care System in Transition

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Estonian health care

system in transitionThe hospital point ofview

HOPE Study Tour No 4 for SeniorHospital Professionals and Managers

21.10.2009. Tallinn, Estonia

Dr. Urmas Sule, CEO Estonian Hospital Association

and Foundation Prnu Hospital

Dr. Teele Raiend, Certified quality manager, Foundation

Prnu Hospital


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We will

Talk about the key actors in healthcare

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 hospitalsrole

Quality management development

And we expect for active discussion!


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The Republic of Estonia

Parliamentary republic, president elected for 5years (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%, Belorussians1%, Finns 1%, other 2%)

Independent since 24.02.1918, occupied by theSoviet Union 1940, regained the independenceon 20.08.1991. Member of the European Unionsince May 1st 2004.

We have been here since 6500 BC!


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Basis for the Estonian

Health Care According to the Estonian Constitution, 10, social

justice in Estonia is a state-based right. Thismeans, that the state must provide the possibility toreceive certain vital services for its citizens, one ofwhich, according to the Constitutions 28, is

everyones right to the protection of health. The right to the protection of health means thestates obligation to engage in both healthpromotion and disease prevention as well as toprovide health services and benefits for persons.

As the states obligations are limited by itseconomic situation, persons do not have the right ofclaim, arising from the Constitution, against thestate in order to receive health services or benefitsto the extent not specified by other Acts.Consequently, persons cannot demand theprovision of all health services. Neither can theydemand the provision of health services completely

free of charge and without a waiting period.


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Key actors

Financing Estonian HealthInsurance Fund

Government, Ministry of Socialaffairs etc legal basis, principlesand supervision

Health care providers:

The workforce

Hospitals (and others) Legislative framework market-

orientation and obligations-regulation


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The Soviet Heritage

Centralized and state-controlled

Over-capacitated provider network

Strategic military network

120 hospitals with 18 000 beds (113 per 10000)

Health care free for everyone, the actual

costs of health care were rarely

considered

Polyclinics

Health promotion and prevention non-

existent?!?


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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


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Four major reforms

Decentralization of health care

administration

Organization of social health insurance

1992- 1994: A situation, were healthcare 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


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Decentralization 1

Decentralization of primary and

hospital care to local administrative

level, where individual or co-

operating groups of municipalitieswould provide both primary and

secondary care

Elimination of special systems Separation of powers


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Decentralization 2

1990: The Statute of the Ministry of Health Care wasendorsed

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 orjointly by the municipality or town councils and themunicipal physician. This includes organization ofprimary and secondary health care and control ofpublic health needs. Decentralization of the healthcare services was stipulated.

The County Physician Act was adopted, determiningits functions. County Physicians were putresponsible for the planning and control of healthcare services at county level, health surveillance andhealth protection of the population. Other levels thatwere listed are municipality and town levels.


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Financing January 1st 1992: Health Insurance Law

From tax-based to insurance-based

Regional Sick Funds

A correlation between health care expenditureand the national economy was established

1994 2002 updated, second-wavelegislation for health insurance

1997: the prices for medical services to be paidby the clients themselves were regulated.

2000: The Estonian Health Insurance Fund Law

was adopted rearranging the institution ofhealth insurance with now only 1 central EHIF.

2002: new era (later).


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Primary health care

1991: Tartu University Medical Faculty started re-specialization courses for Family Practitioners

1993: Family Practitioners specialty was officiallyrecognized

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 contractingmethod with the Sick Fund for 1998

The reorganization of primary health care serviceswas meant to constitute a key element of the health

reforms in Estonia planned by the government. Thecentral principle of this concept was that primarycare should be organized around the familypractitioner who should operate as the gatekeeper,referring his patients to higher levels of care whennecessary. Another aim of reform was to establish

health promotion and prevention.


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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 becentralized to bigger hospitals and long-

term care facilities should be created

2000: Hospital Master Plan


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Case study Prnu

Hospital/ health careservices network


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Health Care providers in

Prnu 1994

Prnu Hospital

Prnu Dermatology Hospital

Prnu Polyclinic

Prnu Childrens Polyclinic

Prnu Pulmonary Cabinet

Prnu Ambulance Prnu Blood Center

Prnu Health InspectionMicrobiology Laboratory


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Prnu Health Care

Reform 1996 - 1998

Development of primary health

care services division family

practitioners practices

Joining practices of differentmedical specialties under one

umbrella

Rights and obligations defined Quality management

Introduction of patient centeredness

Assuring efficiency


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Prnu Health Care

Reform 1994: questions raised, discussions at the local

government

1994: Prnu Hospital development plan (strategy)

1996: partial centralization of special secondarymedical services and separation from primaryhealth care

1998: final centralization of secondary medicalservices

1999: creation of psychiatry clinic

2000: Foundation Prnu Hospital

2002: joiner of Prnu Ambulance to Prnu Hospital

2002: new structure for Prnu Hospital (qualitymanagement enforced)

2004: joiner of blood center to Prnu Hospital

2005: new hospital building

2005: joiner of microbiology laboratory to PrnuHospital


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New era

2001: Health Care Services

Administration Act adopted

(enforced January 2002)

As Health Care Systems 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)


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The implementation of

the Hospital MasterPlan

Discussion

Regionalism

The GoldenCircle


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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 hasstill not been properly discussed

nor approved until today.


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Quality in Health Care

1997 Estonian Health Care Quality Policy

2002 (The Health Care Services AdministrationAct): decrees on quality management andaccessibility; 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 InsuranceFund only purchases quality services


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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?


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Estonian Hospital

Association

representing members;

developing health economics and qualitymanagement;

coordinating the activities of the Association and

exchange of experiences; compiling working groups to solve common

problems of the members;

expressing opinions about health carelegislation and draft acts;

collecting data about health care;

counseling of members

Social dialogueSocial dialogue


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Questions and answersand discussion


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Thankyou!

UrmasEstonian Health Care System in Transition

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