1. Estonian health care system in transition The hospital point of view HOPE Study Tour No 4 for Senior Hospital Professionals and Managers 21.10.2009. Tallinn, Estonia Dr. Urmas Sule, CEO Estonian Hospital Association and Foundation Pärnu Hospital Dr. Teele Raiend, Certified quality manager, Foundation Pärnu Hospital

2. We will… Talk about the key actors in health care 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 hospitals role Quality management development And we expect for active discussion!

3. The Republic of Estonia Parliamentary republic, president elected for 5 years (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%, Belorussians 1%, Finns 1%, other 2%) Independent since 24.02.1918, occupied by the Soviet Union 1940, regained the independence on 20.08.1991. Member of the European Union since May 1st 2004. We have been here since 6500 BC!

4. Basis for the Estonian Health Care According to the Estonian Constitution, §10, social justice in Estonia is a state-based right. This means, that the state must provide the possibility to receive certain vital services for its citizens, one of which, according to the Constitution’s §28, is everyone’s right to the protection of health. The right to the protection of health means the state’s obligation to engage in both health promotion and disease prevention as well as to provide health services and benefits for persons. As the state’s obligations are limited by its economic situation, persons do not have the right of claim, arising from the Constitution, against the state in order to receive health services or benefits to the extent not specified by other Acts. Consequently, persons cannot demand the provision of all health services. Neither can they demand the provision of health services completely free of charge and without a waiting period.

5. Key actors Financing – Estonian Health Insurance Fund Government, Ministry of Social affairs etc – legal basis, principles and supervision Health care providers: –The workforce –Hospitals (and others) Legislative framework – market- orientation and obligations’- regulation

6. The Soviet Heritage Centralized and state-controlled Over-capacitated provider network –Strategic military network –120 hospitals with 18 000 beds (113 per 10 000) Health care free for everyone, the actual costs of health care were rarely considered Polyclinics Health promotion and prevention – non- existent?!?

7. 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

8. Four major reforms Decentralization of health care administration Organization of social health insurance  1992- 1994: A situation, were health care 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

9. Decentralization1 Decentralization of primary and hospital care to local administrative level, where individual or co- operating groups of municipalities would provide both primary and secondary care Elimination of special systems Separation of powers

10. Decentralization2 1990: The Statute of the Ministry of Health Care was endorsed 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 or jointly by the municipality or town councils and the municipal physician. This includes organization of primary and secondary health care and control of public health needs. Decentralization of the health care services was stipulated. The County Physician Act was adopted, determining its functions. County Physicians were put responsible for the planning and control of health care services at county level, health surveillance and health protection of the population. Other levels that were listed are municipality and town levels.

11. Financing January 1st 1992: Health Insurance Law –From tax-based to insurance-based –Regional Sick Funds A correlation between health care expenditure and the national economy was established 1994 – 2002 updated, “second-wave legislation” for health insurance 1997: the prices for medical services to be paid by the clients themselves were regulated. 2000: The Estonian Health Insurance Fund Law was adopted rearranging the institution of health insurance with now only 1 central EHIF. 2002: new era (later).

12. Primary health care 1991: Tartu University Medical Faculty started re- specialization courses for Family Practitioners 1993: Family Practitioners specialty was officially recognized 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 contracting method with the Sick Fund for 1998 The reorganization of primary health care services was meant to constitute a key element of the health reforms in Estonia planned by the government. The central principle of this concept was that primary care should be organized around the family practitioner who should operate as the gatekeeper, referring his patients to higher levels of care when necessary. Another aim of reform was to establish health promotion and prevention.

13. 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 be centralized to bigger hospitals and long- term care facilities should be created 2000: Hospital Master Plan

14. Case study – Pärnu Hospital/ health care services network

16. Health Care providers in Pärnu 1994 Pärnu Hospital Pärnu Dermatology Hospital Pärnu Polyclinic Pärnu Children’s Polyclinic Pärnu Pulmonary Cabinet Pärnu Ambulance Pärnu Blood Center Pärnu Health Inspection Microbiology Laboratory

17. Pärnu Health Care Reform 1996 - 1998 Development of primary health care services division – family practitioners practices Joining practices of different medical specialties under one umbrella Rights and obligations defined Quality management Introduction of patient centeredness Assuring efficiency

18. Pärnu Health Care Reform 1994: questions raised, discussions at the local government 1994: Pärnu Hospital development plan (strategy) 1996: partial centralization of special secondary medical services and separation from primary health care 1998: final centralization of secondary medical services 1999: creation of psychiatry clinic 2000: Foundation Pärnu Hospital 2002: joiner of Pärnu Ambulance to Pärnu Hospital 2002: new structure for Pärnu Hospital (quality management enforced) 2004: joiner of blood center to Pärnu Hospital 2005: new hospital building 2005: joiner of microbiology laboratory to Pärnu Hospital

19. New era 2001: Health Care Services Administration Act adopted (enforced January 2002) –As Health Care System’s 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)

20. At the same time… 2002: The new law for Health Care Insurance and Coverage was adopted, with the idea to cut back on health care expenditures in order to be able to provide more and better quality health care 1995;1999; : The Public Health Law 1995; 2005: The Drug Law

21. The implementation of the Hospital Master Plan Discussion Regionalism The Golden Circle

22. 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 has still not been properly discussed nor approved until today.

23. Quality in Health Care 1997 Estonian Health Care Quality Policy 2002 (The Health Care Services Administration Act): decrees on quality management and accessibility; 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 Insurance Fund only purchases quality services

24. 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?

25. Estonian Hospital Association representing members; developing health economics and quality management; coordinating the activities of the Association and exchange of experiences; compiling working groups to solve common problems of the members; expressing opinions about health care legislation and draft acts; collecting data about health care; counseling of members Social dialogueSocial dialogue

26. Questions and answers and discussion

27. Thank you!