Primary health care in Estonia

Abstract

This article represents an overview about the development and current status of primary health care (PHC) system in Estonia. Since the beginning of 1990s the Estonian health system has undergone comprehensive health reforms, but the in-troduction of a new health care system based on family medicine was recognised as a priority of health care policymakers. The reorganisation of existing PHC in Estonia started with re-training of practicing PHC doctors and introduction of the residency training family medicine. The legal basis for the organisation of PHC was established in 1997 to create a list system and to introduce of partial gate-keeping system as well as new financing principles. Today, most of family doctors are self-employed contractors with the national health insurance fund. The payment for family doctors includes age-weighted capitation fee per registered insured person, funding for lab tests and investigation, basic practice allowance and some additional components, e.g. payment for performance. The evaluations of the Estonian PHC system have demonstrated rather high patient satisfaction and acceptability of the system, first of all in patients living outside the capital, in older patients and in patients with multimor-bidity. However, due to increasing number of the people with chronic diseases the continuous strengthening of the PHC and introduction of chronic disease management models based would be in the focus of future developments in Estonian PHC. Praca opisuje rozwój i stan obecny systemu podstawowej opieki zdrowotnej (POZ) w Estonii. Na początku lat 90. XX w. estoński system opieki zdrowotnej przeszedł kompleksowe reformy, a wprowadzenie nowego systemu opieki zdro-wotnej opartej na medycynie rodzinnej zostało uznane za priorytet przez polityków zajmujących się opieką zdrowotną. Re-organizacja istniejących POZ w Estonii rozpoczęła się od ponownego szkolenia praktykujących lekarzy POZ i wprowadzenia szkoleń dla rezydentów medycyny rodzinnej. Podstawa prawna organizacji POZ powstała w 1997 r. w celu stworzenia syste-mu list oraz wprowadzenia częściowego systemu "gatekeepingu" oraz nowych zasad finansowania. Obecnie większość leka-rzy rodzinnych jest samozatrudnionymi pracującymi na własny rachunek w ramach kontraktu z krajowym funduszem ubez-pieczeń zdrowotnych. Pensja lekarzy rodzinnych obejmuje zależną od wieku stawkę kapitacyjną za każdego zarejestrowa-nego ubezpieczonego, finansowanie badań laboratoryjnych i badań podstawowych, dodatek za prowadzenie praktyki i inne składniki, m.in. wycenę wydajności. Ocena estońskiego systemu opieki zdrowotnej wykazała dość wysoki poziom zadowo-lenia i akceptacji systemu przez pacjenta, przede wszystkim u pacjentów mieszkających poza stolicą, u osób w wieku pode-szłym oraz u pacjentów z wielochorobowością. Ze względu na rosnącą liczbę osób z chorobami przewlekłymi ciągłe wzmoc-nienie systemu POZ i wprowadzenie modeli zarządzania leczeniem chorób przewlekłych będzie w centrum uwagi przyszłych zmian estońskiego POZ. Słowa kluczowe: podstawowa opieka zdrowotna, satysfakcja pacjenta, medycyna rodzinna, reforma systemu opieki zdrowot-nej, finansowanie podstawowej opieki zdrowotnej, Estonia. Estonia is the smallest of the Baltic countries, covering an area of 45 227 km 2 . In January 2015, the population of Estonia was 1 313 271 with 47% men and 53% women. 69% of the population are Estonians and 31% is made up of Russians and other ethnic groups. The average popula-tion density is 29 inhabitants per km 2 . The urban population accounts for 68% of the total population. In recent years, ageing of the population has been observed. The proportion of children (aged 0–14 years) has decreased (from 22% in 1990 to 16% in 2015) and the proportion of people aged 65+ has increased (from 12% in 1990 to 19% in 2015). In 2013, the life expectancy at birth was 72.7 years for males and 81.3 for females [1]. Historical perspective of health care organization and health care reforms In the independent Estonian Republic during 1918–1940, the health care system was based on a principle of decen-tralisation. The organisation and management of the health services, including public health and pharmaceutical ser-vices, was the responsibility of the Directorate of Health and Social Welfare which belonged to the Ministry of Education and Social Affairs. The direct responsibility for the health care of population was delegated to the local municipalities. Mu-nicipality and district doctors were in charge of prevention of disease as well as of treating socially disadvantaged people. However, outpatient medical services were mostly provided K. Polluste, M. Lember • Primary health care in Estonia 75 ~ by private practitioners. There were three types of hospitals, which provided inpatient care: state-owned, municipal and private hospitals. Clinics for mothers and children, sanatoria and mental institutions were state-owned as well. To finance the health care, sickness funds were established in 1920. The sickness funds covered civil servants and employees and were organised on a regional basis [2, 3]. After the Second World War the Semashko system of health care replaced the previous system. The organisation of health care was a responsibility of the state, the physicians were employed by the state, and the health services were funded from the state budget. Primary health care (PHC) was fragmented and the services were provided by district doctors and paediatricians in separate polyclinics for adults, children and women, as well as by specialists in special-ized dispensaries. The institutions providing PHC included village clinics (ambulatories) in rural areas and policlinics for adults, children and adolescents, women's clinics, psy-chiatric and dermato-venerological dispensaries in towns. The health care delivery system focused mainly on curative care and development of excessive hospital network. Thus, the service profile of the PHC doctors were limited, as spe-cialised doctors were directly accessible within PHC (e.g. district doctors for adults and district paediatricians) and, consequently, certain problems almost never reached the PHC doctor [4, 5].