Evaluation of primary health care reform in Estonia
Introduction
Following their restoration of independence, most Central and East European countries began to look for ways to improve the performance and quality of their health care systems (Grielen, Boerma, & Groenewegen, 2000). Common aims in the health care reforms were to strengthen primary care and introduce the family physician, and at the same time, reduce the use of specialist care in order to contain health care costs (Saltman & Figueras, 1997).
The first step in the Estonian healthcare reform was the reorganization of funding of medical care. Instead of funding directly from the state budget, a solidarity-based compulsory health insurance system was introduced in 1992, with contributions paid by employers as a flat 13% surcharge on salaries paid to employees (WHO, 2000a).
The main tasks of the primary health care (PHC) reform in Estonia included introduction of family medicine as a specialty into Estonian health care practice, and changing the remuneration system of primary care doctors. The key elements of the first task included introduction of family medicine courses into the medical school curriculum and retraining of qualified primary care doctors (district internists and district pediatricians) for family medical practice. The changes in PHC started in 1991 with the establishment of a postgraduate training program for family medicine, which in 1993 was designated as a medical specialty (Lember, 1996). Major changes in the remuneration system were designed in 1997 and implemented in 1998.
The Ministry of Social Affairs of Estonia formulated the aims of PHC reform as follows:
- (1)
An effectively operating PHC system should be developed in Estonia by 2003. The reformed health care system should be accessible in residential areas, ensure continuity of medical care, and be implemented by well-educated and skilled family doctors (FDs) who are committed to and accountable for their practice.
- (2)
Management and functioning of the PHC system should follow common principles all across Estonia.
- (3)
The reorganized PHC should pivot around an FD who meets most of the primary care needs of population, is a co-coordinator of care and should operate as a gatekeeper referring her or his patients to higher levels of care when necessary.
The relevant steps of PHC reform included: (1) creating a list system through which the population could register with a primary care doctor, (2) introducing a partial gate keeper and partial fund-holder system, (3) introducing a payment system for doctors based mainly on capitation payments, combined with other minor payments, and (4) rendering to doctors the status of the independent contractor (The Ministry of Social Affairs of Estonia, 1998). It was assumed that the new combined funding system of primary care doctors would be more efficient than the previous fee-for-service system, as has been demonstrated by the implementation of PHC reforms in other countries (Calnan, Groenewegen, & Hutten, 1992; Boerma & Fleming, 1998).
To support and administer PHC reform, policymakers and researchers need to use several indicators for evaluation, and evaluations of reforms in countries that have been changing their health care systems are still rare. In 1997, WHO issued a paper that discussed methods for evaluating the effects of health care reforms (McPake & Kutzin, 1997), but these methods have not been systematically applied in any of the Eastern European countries, making it hard to evaluate and compare the success of health care reforms on the international level (Jee & Or, 1998).
The purpose of this paper is to present a set of indicators that have practical application in evaluating PHC reform in terms of health economics criteria, and to apply these indicators in evaluating the Estonian PHC. It enables a systematic comparison between the planned objectives of reform and the outcomes realized.
Section snippets
Methods
The development of the system of indicators for evaluating Estonia's PHC was started from the five general criteria set out in Appendix A, following McPake and Kutzin (1997), and Knowles, Leighton, and Stinson (1997).
Three economic criteria—allocative efficiency, technical efficiency and financial sustainability—were used by the authors of the current report to develop the system of indicators. This selection was shaped by the limited availability of data that is routinely collected by the
Results
The set of indicators and the empirical values assigned to them for PHC reform in Estonia 1997–1999 is presented in Table 1, Table 2, Table 3.
Discussion
The settings of health care reform differ for each country, depending on its health care characteristics and the goals of the reform. Health care reforms can involve either whole systems, certain parts of health care systems or specific interventions. As it has been observed that every particular indicator shows a change with reform under different conditions, it is more reasonable to use a set of indicators that consider the different parts of health care system (Radical Statistics Health
Acknowledgements
The authors thank Mr. Hans Künka for his help in editing the manuscript. This study is supported by Estonian Science Foundation Grant #3900.
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