Success story of Family Medicine: Estonia

Margus LemberUniversity of Tartu

EURACT Council Member

Turku, 05.05.2006

Why changes?• Low efficiency

• Lack of coordination

• Low comprehensiveness

• Questionable continuity

• Divided responsibility

• Dissatisfaction among population and among providers

Scope of services in 1992Lember M, Kosunen E, Boerma W. Scand J Prim

Health Care 1998

0 10 20 30 40 50 60 70 80 90 100

woman (18), oralcontraception

woman(35), irregularmenstruation

woman(20),confirmingpregnancy

woman (50), lump in breast

B. Women`s problems in PHC

Finnish

Estonian

Procedures in PHC in 1992

26

98

1487

11

92

1090

5

94

4

87

3

84

2

84

281

2

80

2

68

265

0

94

0

53

0 10 20 30 40 50 60 70 80 90 100

wound suturing

setting up intravenous infusion

strapping an ankle

removal of rusty spot from cornea

joint injection

resection of ingrowing toenail

removal of sebaceous cyst from scalp

maxillary sinus puncture

fundoscopy

myringotomy eardrum

insertion of IUD

applying a plaster cast

excision of warts

cryotherapy of warts

Finnish

Estonian

How did DDs perceive themselves as doctors?Virjo I, Mattila K, Lember M, Kermes R, Pikk A,

Isokoski M. Att Primaria 1997;19:407-411

• Similarities between the Estonian district doctors and the Finnish general practitioners

• Social orientation

Favourable situation in 1990s

• primary care doctors- possibility to establish family medicine as a speciality and discipline

• specialists- improving quality of primary care (district doctors) would enable them to perform real specialists` work

• population- possibility to create an alternative health care to the previous system with its drawbacks

• politicians- possibility for a better control of rising health care costs; attracted by the novelty of the idea itself

How to get the first family doctors?

• Import?• Change of medical education for

young generation. But if the health system is not changed?

• Retraining of practicing doctors. • Who should change the system?• Does health care system influence

medical education or vice versa?

“Orthodox” approach in family medicine education

• GPs can be taught only by GPs in general practice

Specialists approach on teaching of family doctors:

• Specialists know best what family doctors must know and do; they have the best knowledge to be transferred to family doctors

International cooperation• WHO course in Tampere, Finland 1989• New Leuwenhorst Group in Tartu 1990

(M.Kvist, C.E Rudebeck, C.Arnold)• Contacts with SIMG, WONCA• Bilateral cooperation: Estonia-Finland

• Ideas, knowledge, inspiration

Chronology of development of Family

Medicine in Estonia• end 1980s, beginning 1990s- first ideas

spread in Estonia• 1991- postgraduate training of Family

Doctors; Society of Family Doctors founded, curriculum change at the University

• 1992- change of funding of health care; Department of Family Medicine at the University of Tartu

Ministerial decree from March, 1993

• Family doctor as a speciality

• Description of a family doctor

• 1995-Estonia /World Bank health project; Estonian Society of Family Doctors full member of WONCA

• 1994-96 unsuccessful preparation of Family Doctor`s law

Ministerial decree from April, 1997

• List system• Fixed number of practices• Family Doctor as independent

contractor• Combination in payment

(basic+capitation+fee-for-service+ bonuses)

• Gate-keeping (partial)

Ministerial decree from October, 1997

• Task description of family doctors

• Payment scheme for family doctors

• New contract since Jan. 1, 1998

15-year development• Training system according to EU

criteria

• Sufficient number of trained FD-s

• Legal aspects: job description, basic equipment, rooms, organization

• Stabile financing

Cumulative number of family doctors

63 63146 162

290

404462

628676

864 907996

0

200

400

600

800

1000

1200

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Was personal care by GPs illusion of the health care

reform?• all health problems• larger scope of services• patient lists• free choice of a doctor• personal care• gate-keeping function• emergency care• 24 h coverage

Estonian family doctors• 100% FD are independent

contractors with sick fund

• 56% FD have solopractices, 44% are working in groups

• 95% women

• GDP per capita (in 2002) 11,018 USD

• Health spending per capita 590 USD in 2002

• Health spending 5.3% of GDP

Contract• Acute cases: same day• Non-acute: within 3 working days

• Practice open: 8 hr every working day• Doctor`s surgery hours: minimum 20 hr

per week (depending on the list size)+ home visits+ other activities

Special features in Estonia

• Changes initiated inside the country, the international support came later;

• Political dynamics of the reforms was supportive

• Close collaboration between the family doctors, University, Ministry of social affairs and Health Insurance Fund

• Close cooperation between the leaders of family medicine and leaders of secondary and tertiary care specialities

• Enthusiasm of doctors• Timely using the “window for reforms” in

society• The leading role of the university• International collaboration.