Estonia

Background

In the early 1990s, funding and provision of Estonian healthcare was separated, and provision was decentralised. Funding was devolved to a Central Sickness Fund with 22 regional branches, and provision mostly to the municipalities. Based on the view that decentralisation resulted in inequities in development and the accessibility of healthcare, a partial recentralisation took place in 2000. The planning of specialist care was moved back to the state level, and the planning and supervision of primary care was moved from the municipal to the county level. Municipalities had previously been unable to effectively carry out these functions due to their small size and weak revenue base.

In 2001, the Estonian Health Insurance Fund replaced the Central Sickness Fund. At the same time, the 17 county-level regional sickness funds were consolidated into 7 regional departments and then, two years later, into just 4 regional departments. This strengthened the EHIF’s purchasing and bargaining power considerably. At the end of 2003 the EHIF covered 94% of the population. One of the major challenges was addressing the decreasing ratio of EHIF contributors and non-contributors. The government tried to address this issue by tightening the eligibility criteria for non-contributory entitlement.

A new version of the Health Services Organisation Act was adopted in 2001. The changes were prompted by a desire to address new phenomena such as the rising cost of drugs, ways of managing decentralised hospital networks and ways of optimising the planning and pricing of health services, notably to transform the patient-doctor relationship into a client-provider relationship. In particular, legal rights, responsibilities and accountability were more explicitly defined in relation to hospital managers in order to create efficiency incentives by affording increased decision making rights to the hospital level. The act also redefined the sickness funds as independent public legal entities in the hope that this would stimulate administrative efficiency.

As drug costs increased much faster than overall health care spending, reform of the reimbursement system was planned and carried out in 2001 and 2002. Outpatient prescription drugs continue to be subject to a co-payment of €3.20 (EEK 50) per prescription, in addition to some of the price of the drug. The general reimbursement rate is 50% of the drug price (minus the co-payment), up to a maximum reimbursement of €12.00 (EEK 200) per prescription.

Recent years

In recent years, Estonia’s health care system has experienced small, rather than drastic, modifications, mainly due to the 2007 Government coalition programme. Here, the government coalitions achieved a general consensus on public health priorities of positive natural growth of the population and improved quality of life. In 2007, participants in all facets of the job market became covered by the mandatory health insurance fund, paving the way for full citizen coverage. However, Estonia’s ageing population poses a long term threat to the sustainability of the health system. In 2007, estimates indicated that non-contributing individuals, such as children and pensioners, constituted almost half of the insured population. Although recently more resources have been allocated towards the healthcare system, the emphasis has been on improving child and maternity care. The Estonian government is actively seeking other sources of funding, as well as how to best target healthcare spending in order to boost the system’s capacity to face shifting demographics.

Current situation

On the whole, Estonia’s reform efforts seem to be heading in the right direction. In 2008, the Health Consumer Powerhouse study ranked Estonia’s health system as first in the category “best value for money” and in line with the average level in other categories among other EU nations. Furthermore, Estonia continues to set long term goals to improve training for nurses and doctors, along with better incentives to keep them from migrating. Moreover, public health reforms have implemented smoking bans, improved access to contraceptives and increased availability of pharmaceuticals for mental health conditions. Although problems with alcohol consumption and HIV transfer continue, long-term plans have been established to battle these issues. For instance, the health ministry has produced strategies for cancer and cardiovascular disease prevention. In addition, it hopes to introduce an e-health information system to include resources not only for prevention, but also for the diagnosis, treatment and monitoring of diseases.

Today, the low level of public expenditure in relation to GDP does cause concern. In 2006, the State’s contribution rate was increased in an attempt to overcome this issue.  Further measures are currently under discussion including expanding the health insurance revenue base and increasing funding to local municipalities. In addition, debates consist of other issues such as expanding private financing and pricing prescription drugs. Funds have been allocated to improve certain services, including IVF (in vitro fertilisation) which has seen an increase in funding, and public infrastructure, (the latter being enhanced with EU funds). These extra funds are expected to help to “scale up public health programmes”.

Estonia statistics

Total Population in 2006: 3,408,000

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