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. The Ministry of Social Affairs was established in 1993 by merging three separate ministries (the Ministries of Health, Social Welfare and Labour). Consequently, the ministry operates in three main areas of policy: health, social services and employment. 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 addition, the Ministry of Finance has a strategic role in health sector by managing the finance of health care through the state budget.

The Ministry of Justice is responsible for the provision and finance of inpatient and outpatient care for imprisoned persons. The Ministry of the Interior organizes the provision of health surveillance in houses of detention for persons kept under constant surveillance but not necessarily in captivity.

The Ministry of Defence manages the medical care system for the outpatient treatment of its employees during military service. Inpatient care is provided in civilian hospitals. Military personnel are covered by compulsory health insurance during their military service, but all the costs of health care and medicinal products are covered by the state budget.

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 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: 

  1. pregnant women whose pregnancy has been identified by a doctor or a midwife;
  2. children and adolescents under 19 years of age;
  3. persons who receive a state pension granted in Estonia;
  4. persons with up to five years left until attaining the retirement age who are maintained by their spouses who are insured persons;
  5. 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:

 

 

Quality and supervision of health care services

To ensure the quality of health services provided to patients in situation where health service is only provided by private legal persons, in 2002, the state established quality requirements for health care service and established surveillance system for monitoring the activities of health care providers.

High-quality health care services must meet the applicable requirements at time of service, including vocational and professional requirements and general level of modern medical science, the resources available, as well as the health status needs and satisfaction of the patient.

Quality requirements for provision of health care services are set out in: 
1) Article 762 of the Law of Obligations Act, according to which health care services shall at the very least conform to the general level of medical science at the time the services are provided and the services shall be provided with the care which can normally be expected of providers of health care services. If necessary, a provider of health care services shall refer a patient to a specialist or involve a specialist in the treatment of the patient;
2) pursuant to the Health Services Organisation Act, the Minister of Social Affairs has established requirements on quality of health service and their availability.

Health care quality problems are assessed and solved by:
1) a health care provider, within their internal quality management system. A health care provider shall ensure the organization of work and quality of management, professional quality of patient service and medical care and assesses patient satisfaction;
2) EHIF that orders clinical audits to assess the quality of health care services in the EHIF’s list;
3) the supervisory department of the Health Board which monitors and evaluates the health services' compliance with regulations, i.e. their formal quality;
4) the advisory expert committee on quality of health care providing an independent opinion on the substantive quality of health care services provided to patients.

The role of health care providers in quality assurance

The obligations of health care providers for the assurance of the quality of service provided have been set by the Social Minister’s Regulation no. 128 of 15 December 2004 on Health Care Services Quality Assurance.

According to this a health care provider is liable for the quality of health care services provided to a patient. The health care provider is required to develop and implement a quality management system to ensure and develop the quality of health care service and to reduce risks related to the provision of health care services. 

Health care quality management system must include:
 1) service quality assurance;
 2) patient satisfaction evaluation;
 3) professional quality assurance;
 4) assuring the quality of institution's organization of work and management.

To ensure patient satisfaction and management of risks related to the provision of health care services, a health care provider should:
1) develop criteria for assessing and analysing patient satisfaction, which ensure patient satisfaction and allow to manage the risks associated with the provision of health care services;
2) develop an organizational customer service standard, and notify patients thereof in their place of activity;
3) inform, in their place of activity, on patient's right, upon a complaint concerning the activities of health workers in the course of health care service provision, to turn to the management of health care service provider, the regional department of health insurance fund or Health Board, and their contact details;
4) at least once a year prepare a patient satisfaction and complaint review, analysis and discussion, and record the results. The results of patient satisfaction analysis shall be published on the public service provider's place of activity, and on their website, if such exists.

To assess the quality of a health care service and to mitigate the risks, a health service provider should:
1)record the transfusion reactions that occurred during the provision of health care service;
2) apply to the expert committee on the quality of medical care for an expert opinion on health care service cases, which caused disputes;
3) use clinical audits, self-assessment, monitoring of medical records;
4) register adverse reactions that occurred during the use of medicinal products and notify the State Agency of Medicines thereof;
5) when providing inpatient care service, to hold regular internal clinical conferences, which would also include relevant medical specialists and family physicians, where appropriate;
6) establish regulations for conducting specialized care councils in order to ensure the quality of inpatient care provided,

To ensure the quality of health care services, a specialized medical care provider shall establish operational guidelines on the following:
1) control and prevention of hospital infections;
2) prescription of medicinal products, including antibiotics with hospital's medicinal product form;
3) prevention and treatment of pressure ulcers;
4) organization of transfusion therapy;
5) assessment of a patient’s pre-operative condition;
6) use of radiation in diagnostic and therapeutic procedures.

The health service providers’ duties on the availability of health care services provided and on waiting lists have been provided by the Social Minister’s Regulation no. 46 of 21 August 2008 "Requirements for the access to health care services and keeping waiting lists".

According to this regulation, a health care service can be provided using waiting lists, if a health care provider is unable to provide the health care service immediately, and if the deferral of health care service to a set deadline does not affect the patient's medical condition, the course of illness or worsen the later prognosis of the illness.
A health care provider shall maintain a waiting list either on paper or in their information system or digital registry.

A health care provider must also display following information in a visible location in their place of operation:
1) reception hours by specialties;
2) contact details of the closest service provider providing required emergency care outside the reception hours and round-the-clock;
3) contact details for authorities to whom to submit complaints and proposals, such as health care service provider, EHIF and the Health Board;
4) maximum lengths of waiting lists approved by the council of EHIF.

The Health Board conducts the supervision on the compliance of the activities of health care providers with established requirements.

The Health Board is a government agency under the governance of the Ministry of Social Affairs which conducts state supervision and enforces powers of a state on the basis and to the extent provided by the law.

The areas of activity of the Health Board are health care, communicable disease surveillance and epidemic control, environmental health, chemical safety and safety of medical devices. The objective of the Health Board is to implement policies aimed at creating a living and learning environment that supports and improves health in these areas. The statutes of the Health Board are available here.

Health care providers must apply to the Health Board for an activity license. An activity license is required for the provision of:
1) ambulance services;
2) primary medical care on the basis of family physicians practice lists;
3) specialized medical care;
4) independent nursing care;
5) independent midwifery care.

To apply for an activity license, a health care provider must meet certain pre-established requirements and before issuing an activity license, the Health Board checks the compliance with those requirements. For example, the license applicant should provide:
- the names and personal identification numbers of health care professionals, and on first application for an activity license, written confirmation from health care professionals agreeing to work for the health care provider applicant;
- when applying for a license to provide emergency care, the number, staff and equipment of ambulance crews;
- when applying for the medical technology part of facilities, a project, which includes the details of facilities, installations and equipment;
- data on the registration of sensitive personal data in data protection supervision authority.

If a health care provider is already licensed, they are obliged to inform the Health Board:
1) immediately of any changes in health care staff;
2) of major technical malfunctions, and other significant changes in the provision of health care equipment, if such failures and changes result in the activity license holder's inability to provide health care services listed in activity license.

In addition, the Health Board monitors all health care providers on their compliance with the requirements provided in established legislation.

EHIF is obliged under the Estonian Health Insurance Fund Act to check whether the services provided were reasoned and of required quality. To monitor this, the following are used:
 - monitoring of health insurance benefits ;
 - clinical audits ;
 - methods for measuring activities and outcomes (clinical indicators); 
 - diagnosis-related groups (DRGs).

To improve the quality of health care services, EHIF also supports the activities of professional associations and medical institutions both in improving the quality of data and in initiating development projects to learn from best international practices.

More information about the role of EHIF can be found here.

Clinical guidelines

EHIF has set up the Guideline Advisory Board with the purpose to improve the quality of health care services provided to patients. In order to achieve this goal, cost-effective and evidence-based Estonian clinical guidelines that take account of local circumstances are prepared, and the process of developing them is led by the Guideline Advisory Board

Clinical guideline is a document which provides recommendations on handling specific health conditions. It provides health workers with evidence-based guidance on various diagnostic and treatment methods and it may also contain recommendations for disease prevention. Information provided in the clinical guideline help make choices between the different intervention methods that affect health, quality of care, and the use of health care resources Initiative for clinical guideline development may come from any organization (e.g. professional association, a group of patients, educational institution, etc.)

All clinical guidelines adopted by the Guideline Advisory Board can be found here.

Waiting lists

Waiting list is a list of persons waiting for a health care service, and it is kept in the registry of health care provider. The duties of health care providers concerning the availability of health care service and the keeping of waiting lists have been provided in Regulation No. 46 of Minister of Social Affairs of 21 August 2008 “Tervishoiuteenuste kättesaadavuse ja ravijärjekorra pidamise nõuded“ (The requirements for the availability of health care services and waiting lists). 
According to this regulation, a health care service can be provided using waiting lists, if a health care provider is unable to provide the health care service immediately, and if the deferral of health care service to a set deadline does not affect the patient's medical condition, the course of illness or worsen the later prognosis of the illness.

The EHIF's supervisory board has set maximum lengths of waiting lists. This is the time period during which a person is entitled to get to a doctor’s appointment. These time limits were set on the principle that a person should be able to receive health care within a time frame, during which their health would not deteriorate significantly.

More information about waiting lists can be found here

In cases, where there is doubt about the quality of medical services, it is recommended to contact the advisory expert committee on the quality of health care services working under the Ministry of Social Affairs.  The expert committee on the quality of health care services is an advisory committee with the purpose to assess the quality of health care services provided to the patient and to make recommendations to the Health Board, EHIF and health care providers on the basis of such assessment.

The committee’s responsibilities include:

1) assessment of the quality of care provided to patients;
2) making proposals to the Health Board to initiate supervision proceedings as a result of the activities of the health care provider;
3) making proposals to a health care provider to assess health care professionals’ competence and to refer employees to in-service training;
4) making proposals to a health care provider for changes in the organization of work;
5) making proposals to the Health Board to revoke the activity license of a health care provider;
6) making proposals to the Health Board to refuse to issue an activity license to a health care provider;
7) making proposals to EHIF to review funding contracts concluded with a health care provider.

An application must be submitted to the expert committee for the quality of health care services, if there is any doubt as to the appropriateness of the provision of health care, a doctor's decision, a medical error or safety of the service. Please, send the application to:

Expert Committee on Quality of Health Care Services, Ministry of Social Affairs, Gonsiori 29, 15027 Tallinn or by e-mail info [at] sm.ee (application must be digitally signed).

Written application must be clear and intelligible, and must include
1) patient's contact information (name and phone number, e-mail address or mailing address); 
2) information of health care provider in question (name of the medical institution, name of the physician or other health care professional and place of service);
3) signed consent (permission) to use the patient’s health data, which is necessary to clarify the circumstances of his or her statement.

If the committee has identified a medical error, they will inform the physician responsible and the medical institution and, if necessary, propose to the professional association that the competence of the medical professional who made the mistake be verified. In its decision, the committee may make suggestions, give advice or recommendations, but may not oblige a physician or medical institution to compensate the patient for the damage caused by a medical error. A patient may turn to court to claim financial compensation.

The State Agency of Medicines is a government agency whose ultimate task is to protect public health through surveillance of medicinal products used in Estonia. The State Agency of Medicines also participates in the protection of animal health by supervising veterinary medicinal products. The State Agency of Medicines is under the administration of the Ministry of Social Affairs.

The State Agency of Medicines has various supervisory functions. The agency assesses the quality, safety and efficacy of medicinal products before granting them a marketing authorization, controls the quality of medicinal products in a laboratory, and supervises the various stages of production, import and sale of medicinal products.
The State Agency of Medicines decides on the admissibility of clinical trials of medicinal products, checks the compliance of the advertising of medicinal products, collects and analyses data on the volume and safety of the use of medicinal products. In addition to its national functions, the State Agency of Medicines has international obligations - to represent Estonia in the pharmacovigilance network of European Union and Council of Europe, providing advice and information in the preparation of normative documents and expertise of medicinal products.