Healthcare management system in Estonia

Estonia’s health care system is built on the principle of compulsory solidarity-based insurance and the general availability of services provided by the private 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.

Estonia's health care system is governed by Health Services Organisation Act, which provides the organisation of and the requirements for the provision of health services, and the procedure for the management, financing and supervision of health care.

Provision of health care is organized according to the specifics of provision:

- provision of emergency care

- provision of general medical care

- provision of emergency medical care

- provision of specialised medical care

- provision of nursing

- provision of midwifery care

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

Health care is financed from the state budget under the health insurance budget through the means of the Estonian Health Insurance Fund, and also through direct allocations from the state budget, and municipal and city budget's, the patient's finances and other sources.

Description of the health system of Estonia

Estonian health system is built on the principle of compulsory solidarity based insurance and the all-round availability of services of private service providers. The Ministry of Social Affairs and its institutions are responsible for the management and supervision of the health care system and development of health policy. 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 health care institutions, and several non-governmental organizations and professional associations are the parties of 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 the 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 population health and organization of public health by determining the extent of general and specialized medical care and public health.

The health sector 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, although all these institutions answer directly to the Minister.

The key tasks of the Health Board include the licensing of health care service providers and the registration of health workers, monitoring the quality of health care services and funding and organization of emergency care services.

The State Agency of Medicines 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. The 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 key task of the Estonian Health Insurance Fund is to be an active purchaser of services, whose responsibilities include signing contracts with health care providers, payment for health care services, compensating the cost of medicinal products, reimbursement of temporary disability costs and payment of maternity benefits.

Additionally, the Ministry of Finance has a strategic role in health sector by finance management of health care through the state budget.

The Ministry of Justice is responsible for the provision of inpatient and outpatient health 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 the course of the military service, but all the costs of health care and medicinal products are covered by the state budget.

In Estonia, the provision of health 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 company owned by local governments or foundations established by state, local governments or other public organizations. Businesses providing family medicine services may only provide general medical care and nursing services. The main rules and initiatives for the prevention of health-care related harm 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 the health insurance fund conducts regular clinical audits of health care services in different health care institutions. In case of treatment errors, the provider of health care service must compensate the patient for the moral and material harm caused by the patient in the course of providing the health care service.

Estonia's pharmaceutical market is strictly regulated. Arrangements are in place for reporting adverse drug reactions directly to the State Agency of Medicines.

The list of health services includes more than 2000 different items. In specialized care, the payment methods include primary the 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 the combination of service-, bed-day- and diagnosis-based payment.

Health care and health care providers

Estonia's health care system is governed by Health Services Organisation Act, which provides the organisation of and the requirements for the provision of health services, and the procedure for the management, financing and supervision of health care.

Health services are the activities of health care professionals for the prevention, diagnosis or treatment of diseases, injuries or intoxication in order to reduce the malaise of persons, prevent the deterioration of their state of health or development of the 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 services, who have applied to Health Board for activity license for provision of health care services. For the purposes of this Act, health care professionals are doctors, dentists, nurses and midwives if they are registered with the Health Board. 

Health Board registries are here.

Provision of health care is organized according to the specifics of provision: 

 - provision of emergency care

- provision of general medical care

- provision of emergency medical care

- provision of specialised medical care

- provision of nursing

- provision of midwifery care

Emergency care means health services which are provided by health care professionals in situations where postponement of care or failure to provide care may cause the death or permanent damage to the health of the person requiring care. Every person in the territory of the Republic of Estonia has the right 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 services is free of charge in emergency care department, permissible visitation fee up to 5 EUR.

NB! Visitation fee is not charged when:

1) outpatient specialized care is provided for pregnant woman, 
2) outpatient specialized care is provided two the insured person under the age of two,
3) provision of emergency outpatient care is immediately followed by the provision of inpatient health care service,
4) the insured person was referred to a specialized care physician by another health worker working same medical institution or a physician working in the same field in another medical institution.

General medical care means out-patient health services which are 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 an appropriate specialized medical care provider 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 the county governor. Persons not satisfied with their family doctor, can change their family physician. This can be done by submitting an application to a new family physician. General medical care provided to persons covered by health insurance shall be paid for from the funds designated for health insurance in the state budget in the amounts in which the Estonian Health Insurance Fund has assumed the obligation to pay for it. Persons not covered by health insurance shall pay for general medical care themselves.

Emergency medical care means out-patient health services for the initial diagnosis and treatment of life-threatening diseases, injuries and intoxication and, if necessary, for the transportation of the person requiring care to a hospital. Emergency medical care works around the clock and is designed to provide immediate medical outpatient care outside the premises of a medical service provider. Emergency medical care specializes in the provision of health care in case of life-threatening health event; emergency medical care provides all possible emergency medical aid on the field and, if necessary, transports the person in need to a hospital.

Each person staying in the territory of the Republic of Estonia has the right to receive emergency medical care. In Estonia, emergency care can be called on alarm centre number 112.Emergency medical care shall be paid for from the state budget through the Ministry of Social Affairs.

Specialised medical care means out-patient or in-patient health services which are provided by medical specialists or dentists and health care professionals working together with them. A hospital is an economic unit formed in order to provide out-patient and in-patient health services.
 Hospital types are regional hospital, central hospital, general hospital, local hospital, special hospital, rehabilitation hospital and nursing hospital.

Specialised medical care provided to persons covered by health insurance shall be paid for from the funds designated for health insurance in the state budget in the amounts in which the Estonian Health Insurance Fund has assumed the obligation to pay for it. Persons not covered by health insurance shall pay for specialised medical care themselves.

Nursing means out-patient or in-patient health services which are provided by nurses and midwives together with family physicians, medical specialists or dentists, or independently.
A nurse is a person who has graduated from basic nursing education and whom a relevant the legislative authority has granted a right to practice nursing in his or her country.
The goal of nursing is to preserve and possible improve the well-established functional status of a patient, long-term treatment and support of patients in stable condition through nursing activities. The subject of nursing is an individual, family or population with their physical, psychological and social needs. Nursing activities are regulated by health service laws, regulations, rules and nursing code of ethics.

Midwifery care means out-patient or in-patient health services which are provided by midwives together with a family physician or medical specialist or independently.
A midwife is a person who, by participating regularly in the country legally approved midwifery training, has successfully completed such training, and thus received competency required in order to be entered in the national register of health care professionals and be legally authorized to practice as a midwife. A midwife supervises, monitors, cares for, and advises women during pregnancy and childbirth, the postpartum period, and in case of gynaecological problems. A midwife participates in health education and family planning for individual, families and on societal level.

The list of health services

The list of health services, for which the Estonian health insurance fund will pay in accordance with established terms, has been provided in Regulation No. 32 of the Government of the Republic of 20 February 2013 the list of health services for the health insurance fund . This list includes all medical treatments, procedures, medications needed by hospitals, and other necessities which are a part of health insurance package. The Estonian health insurance fund pays to medical institutions for services in health insurance list if these have been provided to persons with health care insurance for medical reasons.

The cost of means of service provision, such as devices, instruments, and other, change and the methodologies used in health care and medical management advance. Therefore, the costs also change and funding must go along. Thus, the selection of health services and their prices must be continuously upgraded. Making decision on changes requires previous cooperation with specialists, involvement of experts in their fields and conduct of broad analysis. Health service list is updated in cooperation with hospitals and specialists.

Criteria for changing the list and their assessment conditions and procedures have been set by the Government of the Republic.

The quality and supervision of health services

Table of content:

The quality and supervision of health services

The role of health care service providers in quality assurance

The role of Health Board in quality assurance

 

The quality and supervision of health services

To ensure the quality of health services provided to the patient in situation where health service is only provided by private legal persons, in 2002, the state established quality requirements for health 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 the general level of the modern medical science the resources available and the health status needs and satisfaction of the patient.

Quality requirements for provision of health service are provided in: 
1) Law of Obligations Act § 762, according to which the 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 establishedrequirements on quality of health service and their availability.

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

The role of health care service providers in quality assurance

The duties of health care service 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 the health service provider is liable for the quality of health services provided to the patient and 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.

In assurance of patient satisfaction and management of health-service provision-related risks, a health service provider should:
1) to develop criteria for assessing and analysing patient satisfaction, which ensure patient satisfaction and allow to manage the risks associated with the provision of health services;
2) to develop an organizational customer service standard, and to notify patients in their place of activity;
3) to inform, in their place of activity, on patient's right, upon a complaint concerning the activities of health workers in the course of health 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 to make 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 health care service and to mitigate the risks, the health service provider should:
1) record the transfusion reactions that occurred during the provision of health service;
2) apply for the expert committee on the quality of medical care for an expert opinion on health service cases, which caused disputes;
3) use clinical audits, self-assessment, monitoring of medical records;
4) register adverse effects that occurred during the use medicinal products and notify the State Agency of Medicines;
5) when providing hospital service, to hold regular internal clinical conferences, which would also include relevant medical specialists and family physicians, where appropriate;
6) in order to ensure the quality of hospital service provided, to establish regulations for conducting specialized care councils.

To ensure the quality of health care services, specialist care provider shall establish following operational guidelines:
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 treatment;
5) assessment of patient's pre-operative status;
6) the use of radiation in diagnostic and therapeutic procedures.

The health service providers’ duties on the availability of health services provided and on waiting lists have been provided by the Social Minister’s Regulation no. 46 of 12 August 2008 "Tervishoiuteenuste kättesaadavuse ja ravijärjekorra pidamise nõuded" (Estonian only).

Under this, the health service can be provided using waiting lists, if the health service provider is unable to provide immediate health care, and if the deferral of health service to a set deadline does not affect the patient's medical condition, the course of the illness or worsen the later prognosis of the illness.

Health service provider shall maintain the waiting list either on paper or in their information system or digital registry.

The health care provider must also display following information in a visible location in their place of operation:

1) the office hours by specialty;
2) the contact details of the closest service provider providing required emergency care outside the reception hours and round-the-clock;
3) in case of grievances concerning the availability of health care and for proposals, the health care service provider must list the contact details for authorities to whom to submit complaints and proposals, such as health care service provider, the regional department of the health insurance fund and the county governor and the Health Board;
4) the maximum length of waiting list approved by the council of the health insurance fund.

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

The role of Health Board in quality assurance

Health Board is a government agency under the governance of the Ministry of Social Affairs, which has a management function and conducts state supervision and enforces powers of a state on the basis and to the extent provided by the law.
The objective of Health Board is to implement policies aimed at shaping the living and learning environment supporting and improving health and population health policies aimed at quality health protection and health care in the field of health care, health protection, chemical safety and medical devices.
Health Board Statues can be accessed here.

Health care services can be provided under activity licence requested from the Health Board. A licence is required for provision of:
 1) emergency care;
 2) general health care according to practice lists of family physicians;
 3) specialized medical care;
 4) independent nursing care;
 5) independent midwife care.

To apply for a license, a health care provider must meet certain pre-established requirements, compliance with which the Health Board shall check prior to the issuance of activity licence. For example, the license applicant:
 - provide the names and personal identification numbers of health workers and on first application for activity licence, must provide written confirmation from health workers agreeing to work for the health service provider applicant;
 - when applying for a licence 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 the health care service provider is already licensed, it is obliged to inform the Health Board on continuous basis:
1) immediately of all changes in the 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 licence holder's inability to provide health care services listed in activity licence.

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

The role of Estonian Health Insurance Fund in ensuring the quality

According to the Estonian Health Insurance Fund Act, Estonian Health Insurance Fund (hereinafter health insurance fund) is required to monitor the quality of services, and determine whether the provision of services has been justified. Means of monitoring are:
 - monitoring of health insurance benefits,
 - clinical audits,
 - methods for measuring activities and results (clinical indicators according to health insurance fund),
 - DRG-s.

To improve the quality of health care services, the health insurance fund also supports the activities of a number of professional associations and medical institutions, such as:
 - improving the quality of data, 
 - support and initiation of various development projects, in order to study the best international practices.

Treatment Instructions

The health insurance fund has set up Guideline Advisory Board with the purpose to improve the quality of health care services provided to patients, by guiding development process of cost-effective and evidence-based Estonian treatment guidelines, which take local conditions into account.

Clinical guideline is a document which provides recommendations on actions that effect health. It provides health workers with evidence-based guidance on various diagnostic and treatment methods and it may also contain recommendations for disease prevention and patient education strategies, etc. Information provided in the clinical guideline shall help to make choices between the different intervention methods that affect the 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 the receipt of health care service, kept in the registry of health care service provider. The duties of health care service 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, the health care service can be provided on waiting list basis, if the health care service provider is unable to provide health care service immediately and the deferral of a health care service does not affect the health status of the patient, the course of the illness or worsen the later prognosis of the illness.

The health insurance council has established maximum values for waiting lists. This means the time period during which a person must get to the doctor's appointment. Values 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 on waiting lists can be found here.

The role of expert committee on quality of health services in the quality assurance

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

It is in the competency of the committee to:
1) to assess the quality of care provided to patients;
2) to make proposals to the Health Board to initiate supervision proceedings as a result of the activities of the health care provider;
3) to propose the health care provider to assess health worker's competence and to refer employees to in-service training;
4) to make proposals for health care providers to change their organization of work;
5) make proposals to the Health Board to revoke the activity licence of a health care provider;
6) make proposals to the Health Board to refuse to issue an activity licence to a health care provider;
7) make proposals to the Estonian Health Insurance Fund to review funding contracts concluded with a health care provider.

Application should be sent to:
Expert committee on quality of health services
Ministry of Social Affairs 
Gonsiori 29 
15027 Tallinn 
ESTONIA
or by e-mail at info|ä|sm.ee (application must be digitally signed)

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

If the committee has identified a medical error, it shall inform the doctor and medical institution that made a mistake, and, where appropriate, makes a proposal to professional association to control the competency of the health worker who made a mistake. The committee may, in its decision, make suggestions, give advice or recommendations, but it cannot require a doctor or a medical institution to compensate the patient for the medical error which caused damage. The patient may file a lawsuit, in order to receive financial compensation.

The role of State Agency of Medicines in quality assurance

The State Agency of Medicines is a government agency whose mission 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, through the monitoring of veterinary drugs. The State Agency of Medicines is under the administration of the Ministry of Social Affairs.

The State Agency of Medicines:
•controls the efficacy, quality and safety of medicinal products and issues marketing authorizations for medicinal products;
•monitors the admissibility of clinical trials of medicinal products and monitors the safety of trial participants;
•issues the activity licences for handling medicinal products, monitors pharmacies, pharmaceutical wholesale and manufacturing companies for compliance with the regulation on the handling of medicinal products, also the handling of narcotic and psychotropic substances;
•monitors the movement of narcotic and psychotropic substances across borders of Estonia;
•determines, whether a medicinal product is classified under narcotic, psychotropic, non-prescription or prescription medicines;
•collects and analyses data on trends in drug consumption;
•collects and evaluates information on adverse drug reactions, organizes the communication of related information to international organizations;
•monitors the handling of cells, tissues and organs (except their removal);
•oversees the compliance with the requirements on advertising of medicinal products;
•provides opinions on the applications for entering medicinal products to lists of medicinal products issued by pharmacies under discount;
•organizes the participation of Estonian representatives in European Medicines Agency and European Pharmacopoeia committees and other assemblies;
•helps citizens to receive information on all medication-related issues.