1. Hospital sector Peeter Laasik Assistant Minister,2005-2007 Ministry of Social Affairs, Estonia.

2. 2 ESTONIA Population – 1.356 million Area 45 285 km² Re-independence since 1991 Parliamentary republic 15 counties

3. 3 Health Care Reforms since 1991 A twofold process of change: from centralised and state-controlled health care delivery system towards a decentralised one; from a general state funded system to one based on health insurance. Three main issues: launching of the health insurance system introduction of the family practitioners system restructuring and reorganising of health care system

4. 4 Main actors in the system Ministry of Social Affairs National health care agencies which come under the Ministry of Social Affairs : Health Care Board State Agency of Medicines National Health Protection Inspectorate Health Development Institute Estonian Health Insurance Fund County governments Providers of care Research institutes Associations

5. 5 Regulations in health care The sphere of health care is mainly regulated by the Health Services Organization Act and by the Health Insurance Act. The Health Services Organization Act stipulates the regulation and requirements for providing health care services, directing, financing health care, its supervision and the requirement for health care personnel’s registration. Health care service is an action taken by a health care employee for preventing, diagnosing and curing an illness, injury or poisoning with the purpose of alleviating discomfort, preventing the deterioration of conditions or the progression of diseases and restoring health.

6. 6 Health Services Organisation Act Health care professionals are doctors, dentists, nurses and midwives if they are registered with the Health Care Board. Number of… …doctors: 5342 …dentists: 1390 …nurses: 10234 …midwives:515 All:17481 (Health Care Board)

7. 7 Organisational formLegal form Primary caresole proprietors or companies Specialist care (outpatient)companies, foundations or sole proprietors Specialist care (inpatient)joint stock company or foundation Emergency Carecompany, sole proprietor, foundation or a state or local government rescue service agency Independent provision of nursing companies, foundations or sole proprietors

8. 8 Specialist care Hospitals Joint stock companies or foundations mainly owned by the state or municipality seven types (regional, central, general, local, special, rehabilitation, nursing hospital) Outpatient specialist care companies, foundations or sole proprietors number of outpatient clinics has increased considerably

9. 9 Number of hospitals and outpatient clinics 1992 - 2002

10. 10 List of acute care hospitals approved by the Government 2 regional hospitals (0.5 – 1 million inhabitants) 4 central hospitals (100 000 – 200 000 inhabitants) 11 general hospitals (30 000 – 80 000 inhabitants) 1 local hospitals (less than 40 000 inhabitants)

11. 11 Sources of financing

12. 12 Public health insurance Social health insurance Mandatory Based on solidarity Tax paid by employers proportional as a flat 13% surcharge on salaries paid to employees Coverage 94,7% of the population wider than actual contributors

13. 13 Health Insurance Fund Health insurance budget administrated by Health Insurance Fund Autonomous body legal person in public law established by the Act Supervisory board (15 members) Management board (3-7 members)

14. 14 State budget Emergency medical aid Emergency care provided to persons not covered by health insurance Medical aids for disabled persons Capital investments

15. 15 Hospital sector – integrated care The result a patient expects from the health care system is health. What the care process consists of is irrelevant to the patient. Development plan for hospitals, emergency medical care and family doctors is currently being updated. This can only be done through cooperation. One of the major problems for hospitals is the competition between them. This prevents the development of a natural path between the different stages of hospital care. Tough competition leads to irrational use of resources.

16. 16 The problems on the patient’s level are the speed of reforms and lack of information. People do not know what kind of care is available at which hospital level and about of quality.. There is a lack of beds for nursing care, rehabilitation. The problem on the political level is the unwillingness to continue reforms, since this implies change. Some types of treatment may become unavailable in local hospitals Jobs will be lost The region’s image will suffer

17. 17 The hospital sector needs to be seen from the point of view of the patient’s needs. Continuity of treatment must be ensured. With detalisering of plans the roles of various hospitals are better defined, the quicker the hospitals can mutually cooperate. Hospital sector: 1. Developing of county hospitals which are oriented to the needs of the inhabitants of the region. 2. Hi-tech hospital care.

18. 18 3. Integration within the hospital sector – (hi-tech hospital, county hospital, rehabilitation ho al) 4. From 1 April 2006 a patient may approach any hospital in Estonia for regular medical care. 5. In county hospitals, 91–98% of patients are from the county. The cities of Tartu and Tallinn have a clear regional importance.

19. 19 The share of outpatient surgery and outpatient treatment should be increased by way of decentralisation of simpler services. Hospitals are currently paid for: services, DRG, readiness fee for standby duties Actual devolepment of the hospital sector There is a list of acute care hospitals. We are preparing a list of nursing care and medical rehabilitation hospitals. Cost-based pricing is ABC. We have a price committee that provides the political input regarding health care. Prices are approved by the government. E-health will be applied in Estonia in 2008(digi-recept); a Estonia digital picture bank is available since 2006.

20. 20 Next challenges November 2007- development plan of public health public health health care June 2008 –WHO conference –health system health ministers of 53 countries

21. 21 Thank you for your attention!