Success story of Family Medicine: Estonia Margus Lember University of Tartu EURACT Council Member Turku,

Why changes? Low efficiency Lack of coordination Low comprehensiveness Questionable continuity Divided responsibility Dissatisfaction among population and among providers

Scope of services in 1992 Lember M, Kosunen E, Boerma W. Scand J Prim Health Care 1998

Procedures in PHC in 1992

How did DDs perceive themselves as doctors? Virjo I, Mattila K, Lember M, Kermes R, Pikk A, Isokoski M. Att Primaria 1997;19: 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 postgraduate training of Family Doctors; Society of Family Doctors founded, curriculum change at the University 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 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

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.