All post-Soviet countries moving from a planned to a market economy have tried to reform their health systems. Most have focused on introducing new models of primary health care based on family medicine, but with uneven results. By contrast, Estonia has succeeded in taking its reforms nationwide. How has it achieved this?

Estonia is a small Baltic state which gained its independence from the Soviet Union in 1991 and joined the European Union in 2004. Under communism, its health system consisted of a network of secondary care institutions such as polyclinics. Primary health care (PHC) was fragmented, while family medicine did not exist as a medical specialty. Research led by Imperial College London evaluated the wide scale PHC reforms which Estonia has undertaken since independence.

From 2003-2004, the team analysed routine health service data from the Estonian Health Insurance Fund (EHIF), alongside surveys, policy reports, laws and regulations, and qualitative interviews with policymakers and health care staff. They found that Estonia moved from a tax-based system to a mixed system in 1991, combining payroll taxes with transfers from the state budget and official out-of-pocket payments. Health insurance revenues and budget transfers were pooled at the EHIF, covering 94 percent of the population.

In 1992, Estonia separated planning, purchasing and provision of services. Family medicine (FM) became a specialty the following year with a three-year graduate programme and in-service training for PHC specialists. In 1997, Estonian citizens were required to register with family practitioners who received contracts with EHIF. Results showed that:

• Health policymakers introduced reforms to rural areas before piloting them in the capital, Tallinn
• Between 2000 and 2003, the number of FM consultations for ischaemic heart disease and angina, heart failure, asthma and diabetes increased by 53 percent, while consultations for depression rose by almost 350 percent.
• More emphasis on prevention led to a sharp reduction in unnecessary prescriptions.
• Evidence-based guidelines for management of diseases reduced referrals to specialists.
• Between 2001 and 2004, the number of trained FM specialists increased from 557 to over 900, enough to cover the whole country.
• The majority of Estonians accept the new PHC model, with 88 percent describing themselves as very satisfied with PHC services in a 2003 survey, while 90 percent knew their personal family practitioner.

The key to the success of Estonian health reforms was that organisational, financing, provider payment system and service delivery reforms were introduced simultaneously. These multifaceted reforms were introduced in areas where there was least resistance and with political astuteness that avoided confrontation.

The researchers note the importance of financial and provider payment system reforms in Estonia’s success. In particular, the move to a mix of payment methods gave an incentive for family practitioners to improve organisation and delivery of care, including better management of chronic illness. They identify other key lessons:

• Health policymakers’ gradual approach to spreading their reforms helped prevent opposition from narrow specialists.
• A simple system of payment and contracts ensured support from FM specialists who could understand the changes being introduced.
• Early investment in training and involvement of FM specialists in policy discussions ensured that reforms were rapidly put into practice.
• Use of contracts provided security and a relative advantage to family practitioners, encouraging them to take up the innovation. 

Source(s):
'Introducing a complex health innovation – primary health care reforms in Estonia (multimethods evaluation)', Health Policy 79(1), pages 79-91, by Rifat Ali Atun, Nata Menabde, Katrin Saluvere, Maris Jesse and Jarno Habicht, 2006 (PDF)
HINARI subscribers can access the full-text article here. Full document.

id21 Research Highlight: 4 December 2006

Further Information:
Rifat Ali Atun
Centre for Health Management
Tanaka Business School
Imperial College London
South Kensington Campus
London SW7 2AZ
UK

Contact the contributor: r.atun@imperial.ac.uk

Centre for Health Management, Tanaka Business School, Imperial College London, UK

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'Coping, just – access to care in the new Bulgarian health system'

'Setting the right health goals for Eastern Europe and Central Asia'

'The cost of free healthcare: under-the-counter payments in Bulgaria'

WHO evaluates a decade of Estonias primary health care reform

'Evaluation of Primary Health Care Reform in Estonia from Patients’ Perspective: Acceptability and Satisfaction', Croation Medical Journal 45(5), pages 582-587, by Kaja Põlluste, Ruth Kalda and Margus Lember, 2004 (PDF)

Estonian Health Policy, Ministry of Social Affairs, Estonia