Organization of the health care system in Estonia
The Estonian health care system is based on compulsory solidarity-based health insurance. Health care services are made available mostly by private service providers. The management and supervision of health care system and development of health policy is under the scope of the Ministry of Social Affairs and its agencies.
In Estonia, the health care system is governed by the Health Services Organisation Act, which provides the organization of and the requirements for the provision of health care services, as well as the procedure for the management, financing and supervision of health care.
Provision of health care is organized according to the specifics of the service:
- emergency care
- ambulance
- primary care
- specialized medical care
- nursing care
- midwifery care
Health care is financed mostly from the state budget under the health insurance budget through the means of the Estonian Health Insurance Fund, as well as through direct allocations. Health care also gets finances from the rural municipality and city budgets, through patient deductible fees (e.g. fees of medical specialist visits) and from other sources.
The Estonian health care system is based on the health insurance that employs the principle of solidarity. This means that health care is financed with the social tax paid on the wages of employed people, and all insured people have access to medical care.
The management and supervision of health care system and development of health policy is under the scope of the Ministry of Social Affairs and its agencies. The key institutions responsible for planning, management, regulation and funding of health system functions are the Ministry of Social Affairs and institutions under its management, such as the State Agency of Medicines and the Health Board and the public independent institution Estonian Health Insurance Fund. Publicly owned hospitals and private primary care institutions, and several non-governmental organizations and professional associations are also parties to a complex organizational structure of the health care system.
The state, through Ministry of Social Affairs and its agencies, is responsible of the development and implementation of the overall health policy, including the development and implementation of public health strategies and the monitoring of quality and availability of health care services. The main task of the ministry is legal regulation of health sector. In health sector, the key tasks of the Ministry of Social Affairs include the development of health policy, monitoring of population health and organization of national health system.
The health department of the Ministry of Social Affairs coordinates the activities of the Health Board, the State Agency of Medicines and the National Institute for Health Development, while all these institutions report directly to the Minister.
The key tasks of the Health Board include the licensing of health care providers and the registration of health care professionals, monitoring the quality of health care services and funding and organization of emergency care services.
The State Agency of Medicines is responsible for ensuring that medicines used in Estonia are effective, of high-quality and safe, that they are used for their intended purpose, and their import/export and distributions follows established set of rules. Clinical trials conducted in Estonia and cells, tissues and organs used in the treatment of people are under the supervision of the State Agency of Medicines.
The National Institute for Health Development is responsible for applied research and analysis of public health, environmental health and communicable diseases, and is also involved in the surveillance and reporting on the public health status.
The Estonian Health Insurance Fund is an active purchaser of services, with responsibilities including signing contracts with health care providers, payment for health care services, compensating for the cost of medicinal products, payment of temporary incapacity for work benefits.
In Estonia, the provision of health care services is almost completely decentralized. Health care services may be provided by persons and institutions who act as legal persons governed by private law: companies, foundations or sole proprietors. Most hospitals are either public limited companies owned by local governments or foundations established by the state, local governments or other public organizations. Businesses providing primary care services may only provide general medical care and nursing services.
The main rules and initiatives for the prevention of health-related damages are based on the Health Services Organisation Act and the Law of Obligations Act. Estonian health care system does not record medical errors on systematic basis, but EHIF conducts regular clinical audits of health care services in different health care institutions. In case of treatment errors, the health service provider must compensate the patient for any moral and material harm caused to the patient in the course of service provision.
Pharmaceutical market is strictly regulated in Estonia. There is a procedure in place for reporting side effects of medicinal products directly to the State Agency of Medicines.
The list of health care services includes more than 2,000 different services. In specialized medical care, the payment methods include service, bed-day and diagnosis-based payments. In outpatient care, the main payment method is service-based payment (laboratory tests, radiology, etc.); in inpatient care, the payment method includes a combination of service-, bed-day- and diagnosis-based payment.
Health care and health care providers
Health care services are the activities of health care professionals for the prevention, diagnosis or treatment of diseases, injuries or intoxication in order to reduce persons’ malaise, prevent the deterioration of their state of health or exacerbation of a diseases, and restore their health. Health care service can be either outpatient (a person does not need to stay at a hospital twenty-four hours a day), or inpatient (a person needs to stay at a hospital twenty-four hours a day).
Health care providers are health care professionals or legal persons providing health care services, who have been granted by the Health Board an activity license for provision of health care services. In terms of law, health care professionals are doctors, dentists, nurses and midwives, if they are registered with the Health Board. Health Board registries can be found here.
Provision of health care is organized according to the specifics of the service:
- emergency care
- ambulance
- primary care
- specialized medical care
- nursing care
- midwifery care
Emergency care is a health care service provided by a health care professional in a situation where deferrals or failure to provide assistance may result in death or permanent health damage to the patient. Every person in the territory of the Republic of Estonia is entitled to receive emergency care and all health care professionals are required to provide emergency care within the limits of their competence and with the means available. Provision of health care services is free of charge in emergency care department, permissible visit fee is up to 5 or 20 euros.
Ambulance is a health care service for the initial diagnosis and treatment of a life-threatening illness, injury or poisoning and, if necessary, for transporting a person in need to a hospital. Ambulance is on duty around the clock and is intended for providing emergency medical care outside a health care provider's premises. Ambulance specializes in providing medical assistance with life-threatening health conditions, but in the field, ambulance crew provides all possible medical first aid and, if necessary, transport the person in need to the hospital. Any person on the Estonian territory is entitled to ambulance service. For calling an ambulance, a single emergency number 112 is in use in Estonia. EHIF pays for the ambulance service.
Primary medical care is a health care service provided by family physicians and health care professionals working together with them. In case of illness, a person's first point of contact is their family physician. The family physician provides general medical care and advice on disease, injury or poisoning prevention for all the people in their practice list. If necessary, the family physician refers the patient to a medical specialist for a consultation or to a hospital.
Every insured person has their own family physician, whom they have either chosen by themselves, or who has been assigned to them by local municipality. Persons not satisfied with their family physician, can change their family physician. For this you have to submit an application to a new family physician.
Primary medical care provided to an insured person is paid by EHIF that uses the funds provided for health insurance in the state budget. Persons not covered by health insurance shall pay for primary medical care themselves.
Specialized medical care is a health care service provided by medical specialists and health care professionals working together with them. Hospitals provide outpatient and inpatient specialized medical care services. Hospitals are divided into regional hospitals, central hospitals, general hospitals, local hospitals, specialized hospitals, rehabilitation hospitals and nursing hospitals. Specialized medical care provided to an insured person is paid by EHIF that uses the funds provided for health insurance in the state budget. Persons not covered by health insurance shall pay for specialized medical care themselves.
Nursing care is a health care service provided by nurses and midwives together with family physicians, medical specialists or dentists, or independently. Nursing care focuses on preserving and possibly improving the developed medical condition of a patient, as well as long-term treatment and support of patients in stable condition through nursing activities.
Midwifery care is a health care service provided by midwives together with a family physician, medical specialist or independently. A midwife supervises, monitors, cares for, and advises women during pregnancy and childbirth, postpartum period, and in case of gynaecological problems. A midwife participates in health education and family planning at individual, family and society level.
Financing and list of health care services
The list of health care services includes all medical treatments, procedures, pharmaceuticals needed by hospitals, and other necessities which are part of health insurance package. EHIF pays to medical institutions for services in the health insurance list if these have been provided to insured persons for medical indications.
The cost of means of service provision, such as devices, instruments, etc., change and the methodologies used in health care and medical management advance. Therefore, costs are also changing and funding must be in line with that. Thus, the selection of healthcare services and prices must be constantly updated. Making decision on changes requires previous cooperation with specialists, involvement of experts in their fields and conduct of broad analysis. The list of health care services is updated in cooperation with hospitals and specialists. The criteria for changing the list and their evaluation conditions and procedures have been set by the Government of the Republic.
Health care services funding
Health care is financed mostly from the state budget under the health insurance budget through the means of the Estonian Health Insurance Fund, as well as through direct allocations. Health care also gets finances from the rural municipality and city budgets, through patient deductible fees (e.g. fees of medical specialist visits) and from other sources. Compulsory health insurance has been in force in Estonia since 1992. Health care funding is regulated by the Health Insurance Act.
Health insurance is a system for covering health care expenses incurred to finance the disease prevention and treatment of and purchase of medicinal products and medical devices for insured persons and to pay benefits for temporary incapacity for work and other benefits.
An insured person is a permanent resident of Estonia or a person residing in Estonia on the basis of a temporary residence permit or the right of residence or a person legally staying and working in Estonia based on a temporary ground for stay for whom an employer must pay social tax or who pays social tax for themselves The following persons for whom social tax is not paid are considered to be equal to insured persons:
- pregnant women whose pregnancy has been identified by a doctor or a midwife;
- children and adolescents under 19 years of age;
- persons who receive a state pension granted in Estonia;
- persons with up to five years left until attaining the retirement age who are maintained by their spouses or registered partners who are insured persons;
- persons acquiring basic education (up to 21 years of age)or general secondary education (up to 24 years of age), persons acquiring formal vocational education and higher education students who are permanent residents of Estonia and study in an educational institution in Estonia founded and operating on the basis of legislation or in an equivalent educational institution abroad.
EHIF pays for insured person’s:
- health care services that are entered in the list of health care services of the Estonian Health Insurance Fund and are provided for medical indications;
- for the retail sale of medicinal products necessary for outpatient treatment and included in the list of medicinal products of the Estonian Health Insurance Fund and special foods intended for medical use;
- for necessary medical devices that are included in the list of medical devices of the Estonian Health Insurance Fund.
Quality and supervision of health care services
To ensure the quality of healthcare services provided to patients in a situation where the services are offered exclusively by private legal entities, the state established healthcare quality requirements in 2002 and created a supervisory system to monitor the activities of healthcare providers.
According to the World Health Organization, a healthcare service is of high quality if it meets professionally accepted standards, complies with the legislative and ethical principles of society, and responds to individuals’ needs and expectations. It should also ensure patient well-being and the best possible outcome, while being delivered according to the principle of achieving maximum results with optimal costs.
Responsibilities related to healthcare quality are shared between the Ministry of Social Affairs, the Health Board, the Health Insurance Fund, healthcare providers, and professional associations of healthcare workers. More information on healthcare quality and quality assurance is available on the website of the Ministry of Social Affairs (information available in Estonian).
