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Estonia Healthcare

Healthcare system in Estonia has seen profound reform since early 1990s. Among the main objectives of the healthcare reform were reorganising the public funding system and the overextended hospital system, improving the quality and accessibility of general medical care service, and a more efficient use of resources, including reform of primary care, which began in 1991, and was successfully completed by 2003. The training and introduction of family doctors was central to this reform.

The main source of healthcare finance are the public health insurance, accounting approximately 66% and people’s own contribution, 21% of total expenditure on healthcare over last years. Other public sources include state and municipal budgets, accounting approximately 8% and 2% of total healthcare expenditure respectively. So, healthcare in Estonia is mainly financed publicly. The total costs of healthcare in Estonia in recent years have been 5-5.4% of GDP (5.1% in 2005). If the real growth of total costs of health care was 34% during the period 1998-2003, then the share of public sector grew by 14% and people’s own contribution by over 100%.

Health insurance in Estonia is organised by the Estonian Health Insurance Fund (EHIF) and its four local departments. The EHIF is the only organisation in Estonia dealing with compulsory health insurance.

All persons insured with the EHIF have a family practitioner. A person not residing in Estonia may also visit a family practitioner. A person needs a referral from the family practitioner to visit a medical specialist. No referral is needed to visit a psychiatrist, gynaecologist, dermato-venerologist, ophthalmologist, dentist, pulmonologist (for tuberculosis treatment), infection specialist (for HIV/AIDS treatment), surgeon or orthopaedic (for traumatology).
In the case of emergency treatment, a person may always go to the emergency reception or call an ambulance. The attending physician decides whether the patient needs in-patient treatment.

The amount of the patient’s financial participation in the following cases:

• out-patient examination – a family practitioner can charge a visit fee of up to EEK 50, when making a home visit;
• specialised medical care – a visit fee up to EEK 50;
• transportation by ambulance in the case of emergency – free of charge;
• hospitalisation – an in-patient fee of up to EEK 25 per day and for up to 10 days per hospitalisation.

There is no in-patient fee:

• for children below the age of 2;
• in cases related to pregnancy and childbirth;
• in the case of intensive care.

After independence, underinvestment in health facilities and human resources was a major source of cost savings, resulting in low salaries and poor morale among doctors and nurses. Between 1991 and 2000, the number of doctors fell by 24%, and the number of nurses by 14%. Although the number of doctors and nurses continued to decrease after 1998, the ratio per 1000 inhabitants has remained more or less the same due to a parallel fall in the size of the population.

When healthcare reforms began to take place in the early 1990s, it was assumed that there was an oversupply of doctors, particularly in certain specialities. Thus, it was planned to fund the admission of 100-110 new residents and 90-100 new medical specialists residents every year to ensure the set target – 3.0 doctors per 1000 people by the year 2015.

Currently, there are 3.7 doctors per 1000 people, but continuing the training of doctors at the level of present output with taking into consideration the current age distribution of doctors, it is not possible to maintain even the existing number of doctors sufficiently. The further fall of 12%, (about 500 doctors) is expected already by 2010.

The migration of young doctors has became growing problem for Estonian healthcare system today. The reasons for that are relatively low pay and poor working conditions. For example, from 106 graduates in 2005, 56 continue their medical career in Estonia.

Between 1991-2000 the number of nurses fell by 14%. Reasons for shortfall include poor salaries, high levels work-related stress, low job satisfaction and low professional status.

Currently, there are about 7 nurses per 1000 people. 57% of them work in hospitals and the greatest need is in specialist areas. The Ministry of Social Affairs has already recognised that the increasing shortage of nurses threatens the further implementation of hospital reforms, which include major increases in long-term and nursing care capacity. In 2004, it put forward a proposal to the Ministry of Education to fund training for 500 basic nurses plus 200 specialist nurses, also the extra training was needed due to the fact that 28% of nurses are 50 years or older. The proposal was based to meet the target of 8-9 nurses per 1000 people by the year 2015. However, while there is political will to increase the number of nurses being trained, according to the most optimistic prognosis and not taking into account the possible emigration we could reach a level where there are only 7,5 nurses per 1000 people by the year 2015.




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