1. Free movement in Health Care : Estonian perspective of the Finnish-Estonian case Maris Jesse Former Chairman of Management Board Estonian Health Insurance Fund

2. Estonia and Finland Distance 80 km Transport : By boat 90 minutes over 10 times a day with 12–20 € By Helicopter 18 min. 14 times a day every hour with 70-200 € Similar languages Close ties between medical organisations Close proportion of health care expenditure of GDP : Finland 6,9 % in 1999 Estonia 6,5 % in 1999

3. Facts of Life - Health Care in 1999 EstoniaFinland Average Life Exp.70,7 years 77,3 GDP per capita 3 484 €22 465 € Total Health Expenditure per capita 219 Euro €1 536 Euro € Per 100 000 pop Doctors 321305 Nurses5871361* (*overestemated) Source : NOMESCO - 2000

4. Scenario : Estonian doctors and nurses to Finland Income differences of professionals 7-10 times In 2000 Estonian doctors average monthly salary 530 € Nurses average monthly salary 270 € How many will go and for how long ? No data available about present situation and also not about intentions of professionals Motives to work abroad -General study in Dec/2000 Higher Income - 96 % To broaden sight – 87 % Professional development – 78 %

5. Scenario : Estonian doctors and nurses to Finland First wave to Finland during 1989-1991 Reasons for return : family ties and will to use gained experience in Estonia Some still remain in Finland Second wave currently in progress To substitute for Finnish doctors having freely moved onward to the west Mostly planned only as temporary employment Young professionals ?

6. Opinions : Estonian doctors and nurses to Finland Not seen as a threat neither by officials nor by medical professionals In a small country like Estonia a necessity for professional development Medical profession opinion-leaders see as opportunity to argue for increase of health care financing

7. Scenario : Finnish doctors and nurses to Estonia Finnish medical students study in Estonia No data on somebody working in Estonia permanently Increasing long-term co-operation in highly specialised care Finnish specialist consults and/or operates in Estonia, e.g. Pediatric surgery, liver-transplantation Financed by Health Insurance Fund

8. Scenario : Estonian patients to Finland Health insurance pays for treatment not available in Estonia 5 cases for 65 000 € in Finland in 2001 No data on people paying out-of-pocket, presumingly marginal Estonian health care satisfaction study 2001 87 % of respondents having visited a specialist evaluated as very good or good 70 % of all respondents evaluated quality as very good or good High level of co-payment in Finland an obstacle

9. Scenario : Finnish patients to Estonia Spas along Estonian sea coast-line and on islands : 77 % of guests foreing, mostly Finnish Day price 17-54 €

10. Scenario : Finnish patients to Estonia Dental treatment Up to 10 % of patients in central Tallinn Implants, protheses etc Plastic surgery Cardiac surgery 1989-1992 Time of long waiting-lists Contract between Finnish Heart Association and a hospital in Estonia Appr. 100 Finnish patients were operated in Estonia Failed due to a error during blood-transfusion leading to large-scale negative media-coverage in Finland Preliminary interest raisen again

11. Current expectations and opinions for post-accession period in Estonia : Movement of health professionals is vital for a small country like Estonia Becoming a member-state simplyfies movement of professionals, but would not change current numbers Threat of “brain-drain” is seen as negotation power for increased health finance Painful memories from first attempt at international competition in health care Co-operation valuable to doctors and patients in both countries