Estonia: Establishing family medicine as a specialty to strengthen primary health care
Family medicine focus
World Bank/Curt Carnemark
Since Estonia gained independence from the Soviet Union in 1991, the country has made significant progress on improving health outcomes, in large part through a transformation of the health system to reflect a commitment to primary health care (PHC). Recognizing the importance of training and motivating PHC providers, in 1993 Estonia established family medicine as a medical specialty with the goal of training a cadre of recognized PHC providers to serve as the point of first contact and gatekeepers to other health services [1-5]. Nurses were also able to specialize in primary health care. This focus on ensuring effective and quality primary health care delivery was reinforced by national leadership through the Health Services Organization Act of 2002, which stated that the PHC provider must act as the first point of contact for care and that family doctors were the main providers of PHC.
The system of primary health care in Estonia is designed to provide strong people-centered integrated care.
An important step was making PHC a specialty, which helped create a culture in which family medicine is respected and becomes the first contact in the health care system with family doctors and family nurses providing comprehensive and continuous care [6, 7]."
Patients are encouraged to have their first visit be with a family doctor or they must pay the full cost of any subsequent specialist visit . To further decrease the reliance on specialists, the role of family doctors in the care of individuals with chronic illnesses has also been strengthened. Family doctors receive specialist training and, starting in the 1990s, evidence-based guidelines for the management of acute and chronic conditions were introduced to further standardize the provision of high-quality care. These guidelines provided family doctors with the knowledge to effectively manage these patients in the PHC setting and reduce complications and referrals to specialists . Use of these guidelines continues to be inconsistent because of resource constraints .
Leadership commitment to care
Strong leadership provided by three chief actors in the Estonian health care system—the Ministry of Social Affairs (MoSA), the Estonian Health Insurance Fund (EHIF), and family doctors—was critical to the success of primary health care reform [2-4]. Spearheading the health care reform, the MoSA established an emergency care fund for the uninsured to guarantee universal access to care [3, 5]. With the Social Health Insurance, EHIF operates the national mandatory health insurance scheme and is responsible for a number of quality improvement activities including clinical audits and the Quality Bonus Scheme. This scheme incentivizes effective management of patients with chronic conditions and strengthened horizontal integration in PHC settings through delivery national disease prevention activities such as breast and cervical cancer screening and child immunizations through PHC .
Estonian family doctors also contributed to the success of the health system by developing Diagnosis Related Groups that more accurately track hospital-related costs for the purposes of budget allocation . Demonstrating a commitment to ongoing learning, Estonia continuously makes adjustments to its initial reform, such as updating the essential drug list, providing more autonomy for service providers, and centralizing organizational aspects of PHC [3, 4].
Jessca Ziegler/Courtesy of Photoshare
The Estonian Health Insurance Fund has also encouraged empanelment, by the process of assigning patients to a primary care team using fixed geographic areas, contracting with family doctors to ensure timely access to care and coverage for services to covered populations [5, 8]. Through geographic empanelment, practice-based patient registers are created and all Estonians must register with a family doctor. Each practice serves between 1200 and 2000 patients [2, 4, 5]. Family doctors are assigned to a cover a geographic area assigned by the county governor, and only 10 percent of individuals change physicians within a year . There is some provider flexibility—a family doctor can reject a patient in two cases: 1) their patient list is full and 2) the patient is outside of the family doctor’s geographic region , though in both cases only if the new member is not related to an already-registered patient.
The financial incentives are designed to encourage not just productivity but also quality. In 2006 a payment policy for performance indicators began and while not mandatory, in 2007 60 percent of family doctors were participating . At the start of the health care system reform, the government calculated that 807 family doctors would be necessary to achieve this coverage , with approximately 800 family doctors practicing in Estonia by 2003 .
Improved access and continuity
Patient access to, and utilization of, primary health care increased with the introduction of family medicine as the core of PHC in Estonia and the establishment of empanelment . Family doctors must have at least 20 hours of visit time and one evening clinic per week, plus the practice must remain open for a minimum of eight hours per working day [2, 5]. Patients with acute conditions must be able to have an appointment on the same day that it is requested and patients with chronic diseases must be able to see the physician within three days .
Tele-medicine was also introduced in 2005 to further ensure access for patients through the Family Doctor Hotline, a 24-hour phone line that residents, particularly those in rural areas, can call for consultations . This hotline is available for all citizens regardless of insurance status (i.e. migrants who remain uninsured) or type, and the first five minutes of hotline consultation are free of charge .
A strong eHealth system has also been critical to the success of primary health care system in Estonia, helping to ensure coordination and continuity of care. [2-4]. Each patient has a single national record that documents medical history, test results, diagnostic imaging, and prescription history. This record effectively links all service providers, patients, and the Estonian Health Insurance Fund across the country . This comprehensive IT system currently covers 71 percent of the population, and 100 percent of pharmacies have joined the complementary prescription system resulting in 93 percent of prescriptions in 2011 being completed online [3, 4].
Near universal coverage
The primary health care reforms led to important service delivery and outcome improvements:
- Estonia has reached near universal health coverage through EHIF and SHI and 95 percent of its population is now covered for both curative and preventive services [1-4].
- There are an estimated 800 family doctors, 70 percent of whom work in their own private practices [2, 5].
- More than 90 percent of the population reports knowing their primary care physician well
- More than 85 percent of the population reports high levels of satisfaction with care .
- Hospital admissions began to fall in the late 1990s and the country has been able to reduce the number of hospitals from 120 to nine .
- Life expectancy at birth rose from 69.8 years in 1991 to 76.6 years in 2011
- Child mortality decreased from 16.7 deaths per 1000 live births in 1991 to 3.1 deaths per 1000 live births in 2011 .
Staffing and resource challenges
Despite these successes, several challenges remain [5, 6]. In general, there is a shortage of family nurses, particularly for the provision of home-based care services . Fragmentation remains a challenge, especially with post-discharge care and timely follow up in the primary care clinics. Additionally, the primary health care clinics need to be updated in order to accommodate a growing need for services, but this comes at a price due to the expense of land and rent, particularly in cities. . These infrastructure gaps limit the expansion of family doctor practices .
In addition, the national system currently recommends that family doctors are recertified every five years and participate in continuing medical education courses, but completion rates are low, a challenge which threatens effective uptake of new knowledge and practices. . Finally, Estonia, like many countries, is in the midst of epidemiological transition due to an aging population and the rise of non-communicable diseases (NCDs). Half of its population is between 30 and 70 years old, and NCDs accounted for 92 percent of deaths in recent years, with 50-55 percent attributable to cardiovascular diseases [2, 4]. Now, more than ever, it is critical for the country to continue to strengthen its PHC system and maintain its emphasis on universal access to quality, coordinated, comprehensive and continuous care. The focus of Estonia’s reform on trained providers to serve as first point of contact, with primary responsibility for their patient’s outcomes and effective use of the range of services needed will continue to be critical to maintaining and increasing health gains .
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- The World Bank, The State of Health Care Integration in Estonia. 2015. p. 55.
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- World Health Organization. Estonia 2008 [cited 2015 August 14]
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- Polluste, K., Kalda, R., and Lember, M., Primary health care system in transition: the patient's experience. Int J Qual Health Care, 2000. 12(6): p. 503-9.