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Health reforms in Estonia: acceptability, satisfaction and impact
Nordic Council of Ministers, Nordic School of Public Health NHV.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.

Place, publisher, year, edition, pages
Göteborg: Nordic School of Public Health NHV Göteborg, Sweden , 2007. , 81 p.
Series
NHV Reports and Doctor of Public Health-Theses, ISSN 0283-1961 ; NHV Rapport 2007:1
Keyword [en]
Estonia, Health reforms, Population Health, Access to Health Services, Acceptability, Satisfaction
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:norden:org:diva-3416ISBN: 978-91-85721-00-9 (print)OAI: oai:DiVA.org:norden-3416DiVA: diva2:749206
Public defence
2007-05-21, Nordic School of Public Health NHV, Göteborg, Sweden, 13:00 (English)
Opponent
Supervisors
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
List of papers
1. Patient satisfaction with care is associated with personal choice of physician.
Open this publication in new window or tab >>Patient satisfaction with care is associated with personal choice of physician.
2003 (English)In: Health Policy, ISSN 0168-8510, Vol. 64, no 1, 55-62 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate whether choosing one's own primary care doctor is associated with patient satisfaction with primary health care. To evaluate factors related to population's satisfaction with primary health care.

POPULATION: A random sample of Estonian adult population (N=997).

STUDY DESIGN: Cross-sectional study using a pre-categorized questionnaire which was compiled by the research group of the University of Tartu and the research provider EMOR.

RESULTS: Altogether 68% of the respondents had been listed in their personal physician. Their overall satisfaction with the physician as well as satisfaction with several aspects of primary health care were significantly higher compared with those of unregistered respondents. Although some other factors (practice size, patient age, health status) also influenced patient satisfaction, presence of a personal physician appeared the most important predictor of high satisfaction with physician's punctuality and understanding, effectiveness of prescribed therapy, clarity of explanations given by the physician as well as with overall satisfaction with the physician.

CONCLUSION: Personal doctor system is associated with patient satisfaction with different aspects of care.

Keyword
List system, Choice of Personal Physician, Patient Satisfaction
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3411 (URN)12644328 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
2. Patients' opinions on family doctor accessibility in Estonia.
Open this publication in new window or tab >>Patients' opinions on family doctor accessibility in Estonia.
2004 (English)In: Croatian Medical Journal, ISSN 0353-9504, E-ISSN 1332-8166, Vol. 45, no 5, 578-81 p.Article in journal (Refereed) Published
Abstract [en]

AIM: To investigate the accessibility of family doctors in Estonia from the patients' point of view.

METHODS: Face to face interviews using structured questionnaires were performed. A random sample of the Estonian residents, aged 15-74 years, was studied (n=999).

RESULTS: The number of visits provided by family doctors has been continuously increasing since 1998. Out of 999 respondents, 59% visited the family doctor during the previous 12 months. The average number of visits per Estonian resident in one year is 2.48. Out of 999 interviewed persons, 72% said that they had a possibility of contacting their family doctor by phone. The waiting time for an appointment was short in most cases. The family doctor admitted 60% of the respondents on the same day the patients had requested; 22% of the patients were admitted within 1-2 days and 9% of the patients were admitted within 3-4 days. Only 9% of them had to wait more than 5 days. The current home visit fee in Estonia would have affected the decision of the home call of 58% of people. There was a correlation between the acceptability of a visit fee and the people's income.

CONCLUSION: The accessibility of family doctors can be considered good in Estonia.

Keyword
Family Practice, Health Care Reform, Health Services Accessibility
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3413 (URN)15495284 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
3. Evaluation of primary health care reform in Estonia from patients' perspective: acceptability and satisfaction.
Open this publication in new window or tab >>Evaluation of primary health care reform in Estonia from patients' perspective: acceptability and satisfaction.
2004 (English)In: Croatian Medical Journal, ISSN 0353-9504, E-ISSN 1332-8166, Vol. 45, no 5, 582-7 p.Article in journal (Refereed) Published
Abstract [en]

AIM: To analyze the population's view of the primary health care reform five years after the formal implementation of the reform investigating the acceptability of the primary health care system, patients' preferences, and satisfaction with their family doctors.

METHODS: Face-to-face interviews using structured questionnaires were preformed with a random sample of the Estonian residents aged 15-74 years (n=999).

RESULTS: Out of 999 respondents, 35% prefer to first see their family doctor and if necessary to get a referral or a recommendation to see a specialist. The referral to the specialist by the family doctor is more preferred by older respondents, rural people, by the respondents with a lower level of education and income as well as by people who were more satisfied with their family doctor. The people who were more satisfied with their family doctor found that the whole health care system was functioning better than the previous primary health care system. Out of all the respondents who have had a contact with their family doctor during the last 12 months 87% (n=585) were satisfied with his work. The overall satisfaction with the family doctor depended on 1) perceived competence of the physician (OR=0.624, 95% confidence interval (CI)=0.419-0.933); 2) understanding the patient's problem (OR=0.699, 95%CI=0.496-0.984); 3) punctuality of the physician (OR=1.533, 95%CI=1.075-2.186); and 4) the location of the primary health care center/clinic (OR=0.751, 95%CI=0.574-0.983).

CONCLUSION: During the five-year-period most of the Estonian population has accepted the new primary health care system and the satisfaction rate has increased. Family doctors are in the center of the primary health care systems and their professional competence plays a great role in making the system acceptable for the patients.

Keyword
Family Practice, Patient Acceptance of Health Care, Patient Satisfaction, Primary Health Care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3412 (URN)15495285 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
4. Primary health care system in transition: the patient's experience.
Open this publication in new window or tab >>Primary health care system in transition: the patient's experience.
2000 (English)In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 12, no 6, 503-9 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To find out how Estonian people evaluate the changes in primary health care (PHC), how they perceive the acceptability of the new PHC system, and to assess patients' satisfaction with their primary care doctor.

DESIGN: Face-to-face interviews using structured questionnaires.

SETTING: Estonia.

STUDY PARTICIPANTS: A random sample of Estonian residents aged 15-74 years (n = 997).

MAIN MEASURES: Acceptability of PHC system (accessibility, the patient-practitioner relations, amenities, and patient's preferences) and patients' satisfaction with primary care doctor.

RESULTS: Of the 997 respondents, 46% were sufficiently informed about the transition to the general practitioner (GP)-based PHC system; however, 45% of respondents had not personally experienced any changes. Of the 997 persons interviewed, 68% were registered on the patient list of a GCP, and 62% of those who had health problems preferred to consult the primary care doctor first. The waiting time for an outpatient appointment was brief (0-2 days). Of the 997 respondents, 68% were satisfied with their primary care doctor. Satisfaction was dependent on: (i) how patients evaluated the competence of the physician; (ii) comprehensibility of doctor's explanations; and (iii) comfort of the clinic. The right of patients to choose their own primary care doctor and having sufficient information about the changes in PHC system had a positive influence on the level of satisfaction.

CONCLUSIONS: Patients' opinions are important in the evaluation of PHC. To increase the level of satisfaction, people need to understand the nature and intent of the primary care reforms. Personal choice of primary care doctor and good patient-doctor relationships are important factors too.

Keyword
Acceptability, General Practitioner, Patient Satisfaction, Primary Health Care Reform
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3410 (URN)11202604 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
5. Satisfaction with the access to the health services of the people with chronic conditions in Estonia.
Open this publication in new window or tab >>Satisfaction with the access to the health services of the people with chronic conditions in Estonia.
2007 (English)In: Health Policy, ISSN 0168-8510, Vol. 82, no 1, 51-61 p.Article in journal (Refereed) Published
Abstract [en]

UNLABELLED: After the implementation of the primary health care reform in Estonia, most of chronic conditions are managed by family doctors (FD) in collaboration with specialists. Although the general population has demonstrated the increase in satisfaction with health care after the reform, it has been questioned if people with chronic diseases have been left on a more disadvantaged position in the new system with some restrictions in the access to specialists.

OBJECTIVE: To investigate the satisfaction of people with chronic conditions with the access to the health services and compare them to those who did not have a chronic illness.

METHOD: In November 2005, a random sample of Estonian residents aged 15-74 were personally interviewed using structured questionnaires (n=1446), 29% of them reported to have a chronic illness.

RESULTS: The people with chronic conditions were less satisfied with the access to the health services. They were more satisfied with their family doctors, but less with the health insurance system and they often reported their problems in seeing the specialist. Compared to other respondents, the people with chronic conditions visited their FDs and specialists more often, but no significant differences were found between their waiting times to see the FD or a specialist.

CONCLUSION: In Estonia, the people with chronic conditions do not have organisational barriers in their access to the health services. As frequent users of health services, they perceive the shortages of the health system more obviously than the rest of the population and it may reflect their satisfaction with the different aspects of the health system as well as the access to the health services.

Keyword
Chronic Conditions, Access, Health Services, Estonia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3415 (URN)10.1016/j.healthpol.2006.08.004 (DOI)17011063 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved
6. Public health reforms in Estonia: impact on the health of the population.
Open this publication in new window or tab >>Public health reforms in Estonia: impact on the health of the population.
2005 (English)In: BMJ (Clinical research ed.), ISSN 1756-1833, Vol. 331, no 7510, 210-3 p.Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3414 (URN)10.1136/bmj.331.7510.210 (DOI)16037459 (PubMedID)
Available from: 2014-09-23 Created: 2014-09-23 Last updated: 2014-09-23Bibliographically approved

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