1. Dr Ivi Normet Deputy Secretary General on Health Ministry of Social Affairs Health Care and E-Health system in Estonia

2. Estonia  Population – 1.323 million  Area 45 227 km²  15 counties, 215 municipalities  Urban concentration 68%  POPULATION PROFILE  Sex ratio 1.14 females/males (EU average: 1.05)  Age structure 0 –14 years 16% (EU average: 16)  65+ years 18% (2012) ( EU average 18%)

3. Health system: main actors  Ministry of Social Affairs (MoSA)  National agencies under MoSA:  State Agency of Medicines  National Institute for Health Development  Health Board  Estonian Health Insurance Fund (EHIF)  e-Health Foundation  County governments  Providers of care  Research institutes  Associations

4. Health system: financing  Mainly publicly funded through solidarity based mandatory health insurance contributions in the form of earmarked social payroll tax (Bismarck).  Employers are obligated to pay social tax for employees of which includes 13% of gross wages for health insurance.  The health insurance system covers about 94% of the population.

5. Health system: financing  Financing is mainly organized through the independent EHIF.  EHIF finances outpatient and inpatient services provided to insured persons, and in certain cases also rehabilitation, nursing and dental care services.  MoSA is responsible for financing emergency care for uninsured people, as well as for ambulance services and public health programs.  Local municipalities have a minor, rather voluntary, role in organizing and financing health services.  Private expenditure constitutes approximately 20% of all health expenditure – mostly in the form of co-payments for medicines and dental care.

6. Health system: financing  Estonia spent 5.8% of its GDP on health.  Total health care expenditures in 2012 in constant prices were 344.27 million euros.  The share of public health expenditure in total health expenditure was 80.5% inl. EHIF (69.6%).  The share of households' out-of-pocket expenditure in total health expenditure was 17.8%.

7. Health system: Primary Care  Since 1998 organized around family practices (before in polyclinics and ambulatories).  sole proprietors or found companies.  primary care is the first level of contact with the health system.  every family doctor has a service area and maintains a list of patients.  the practice list cannot exceed 2000 or be less than 1200. Once the 2000 persons limit is reached, an assistant family doctor has to be hired.

8. Health system: Primary Care  All family doctors are required to work with at least one family nurse – to stimulate compliance, the EHIF applies a coefficient of 0.8 on the capitation fee for family doctors working without a nurse: 5 family physicians out of 802.  A shift in responsibility from family doctors to nurses (chronically ill patients, pregnant women and healthy neonates).  Planning and management of primary care access is organized in national level (since 2013 before county level).

9. Health system: Specialist care  A person needs a referral from the family practitioner to visit most of the medical specialist.  Hospitals (61)  Joint stock companies or foundations  mainly owned by the state or municipality (66%)  seven types (regional, central, general, local, special, rehabilitation, nursing hospital)  Outpatient specialist care  companies, foundations or sole proprietors.

10. Legislation and policy documents Main Acts  Health Services Organisation Act;  Health Insurance Act;  Communicable Diseases Prevention and Control Act;  Mental Health Act;  Medicinal Products Act;  Public Health Act.

11. Legislation and policy documents  National Health Plan (NHP) is the main policy document which was adopted by the government in 2008.  The aims is to integrate all existing sectoral health plans, strategies and development plans into one plan that presents linkages between the various stakeholders of the health system and other sectors.  NHP contains measurable targets with specific indicators and a detailed list of activities that are directly linked to the state budget.

12. Legislation and policy documents NHP has yearly multisectoral action plan in 5 fields: I.Social cohesion and equal opportunities; II.Safe and healthy development of children and adolescents; III.Healthy living, working and learning environment; IV.Healthy lifestyle; V.Development of the health care system.

13. Goals for e-health systems  Decreasing the level of bureaucracy in the health care workers work process.  Increasing the efficiency and improving the quality of the health care system.  Making the time-critical information accessible for the attending physician.  Developing more patient friendly health care services.

14. Nationwide E-health system  Launched 2008, after implementing four e-health projects  Electronic Health Record (EHR)  Digital Prescription  Digital Image  Digital Registration  built on state IT infrastructure (uses same solutions – ID card, X-road, etc.).  all health care providers must send data to EHR according to law.  multifaceted system- incl. technological, standardisation, legal, organisational and ethical aspects.

15. eHealth  Estonian eHealth Foundation  Founded 18.10.2005 by main stakeholders  Ministry of Social Affairs  3 biggest hospitals  North Estonian Regional Hospital, Tartu University Hospital, East Tallinn Central Hospital  The Estonian Society of Family Doctors  The Estonian Hospitals Union  Union of Estonian Emergency Medical Services

16. eHealth: EHR System  All patients medical records are gathered from all healthcare providers into one central database that gives healthcare professionals a fast overview of patient diagnoses, medications, laboratory results, vaccinations and other personal data.

17. eHealth: EHR System EHR also enables  patients to access their medical data through patient portal.  to see anonymous but still individual based information for statistics and research purposes as well as for improving health service and measuring quality of treatment.  The coverage of inpatient data in EHR is 100% and 70- 80% on outpatient data but its improving all the time.

18. E-Health: e-prescription e-prescription (2010) aim was to:  satisfy the rising patient expectations (to get the same prescription without visiting doctor);  strengthen ingredient-based prescribing (from 50% in 2010 to 75% in 2012) > OOPP decrease for medicines;  economize doctor's, pharmacist's, patient's time > pre- filled fields (reimbursement rate, former prescription history);  make detailed analyses of the use of medicines.

19. Challenges and directions of developments  Sustaining health expenditure and human resources at levels that ensure timely access to and high quality of care.  This is particularly important in the face of rising patient expectations, ageing of the population (age related morbidity, less financial resources) and as well as increase of cost and volume of health care services.

20. Challenges and directions of developments  Centralization of more sophisticated and high technology special care (competence centres).  Decentralization of frequently needed and more „simple“ care (primary care, some special care).  Concentration to out-patient and day care.  To rise the number of state commissioned education study places for health care workforce.

21. Challenges and developments: Strengthening of primary health care by creating the network of health centres to provide wider scale of services (family practitioner and nurse, home nursing, midwife, physiotherapist, dentist and also integration of public health services etc), to assure good access and cover the needs of ageing population.

22. Challenges and developments: Network of health centres  Restructuring county hospitals into multiprofile health centres by optimisation of ineffective services and integrating limited range of special care and diagnostic services with primary health care services into one infrastructure.

23. Thank you for your attention!