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Health Systems in Transition Vol Health Systems in Transition Vol. 10 No. 1 2008 Estonia Health system review Agris Koppel • Kristiina Kahur Triin Habicht • Pille Saar Jarno Habicht • Ewout van Ginneken Editor: Ewout van Ginneken Health Systems in Transition Written by Agris Koppel, WHO Regional Office for Europe Kristiina Kahur, Estonian Health Insurance Fund Triin Habicht, Estonian Health Insurance Fund Pille Saar, Estonian Ministry of Social Affairs Jarno Habicht, WHO Regional Office for Europe Ewout van Ginneken, Berlin University of Technology Edited by Ewout van Ginneken, Berlin University of Technology Estonia: Health System Review 2008 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration ESTONIA © World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies. Printed and bound in Estonia. Suggested citation: Koppel A, Kahur K, Habicht T, Saar P, Habicht J and van Ginneken E. Estonia: Health system review. Health Systems in Transition. 2008; 10(1): 1-230. ISSN 1817-6119 Vol. 10 No. 1 Health systems in transition Estonia Contents Preface ............................................................................................................v Acknowledgements ..................................................................................... vii List of abbreviations .....................................................................................ix List of tables and figures ...............................................................................xi Abstract ........................................................................................................xv Executive summary ................................................................................... xvii 1. Introduction ..........................................................................................1 1.1 Geography and sociodemography .................................................1 1.2 Economic context .........................................................................3 1.3 Political context ............................................................................5 1.4 Health status ...................................................................................9 2. Organizational structure .....................................................................19 2.1 Overview of the health system ...................................................19 2.2 Historical background .................................................................19 2.3 Organizational overview .............................................................23 2.4 Decentralization and centralization .............................................33 2.5 Patient empowerment ..................................................................35 3. Financing ...........................................................................................43 3.1 Health expenditure ......................................................................45 3.2 Population coverage and basis for entitlement ............................51 3.3 Revenue collection/sources of funds ..........................................62 3.4 Pooling of funds ..........................................................................74 3.5 Purchasing and purchaser–provider relations .............................78 3.6 Payment mechanisms ..................................................................82 4. Regulation and planning ....................................................................91 4.1 Regulation ...................................................................................91 4.2 Planning and health information management .........................103 iii Health systems in transition Estonia 5. Physical and human resources .........................................................109 5.1 Physical resources .....................................................................109 5.2 Human resources ......................................................................118 6. Provision of services ........................................................................135 6.1 Public health ..............................................................................135 6.2 Primary care ..............................................................................142 6.3 Secondary care ......................................................................... 151 6.4 Ambulance services ..................................................................158 6.5 Pharmaceutical care ...................................................................161 6.6 Rehabilitation care .....................................................................169 6.7 Nursing care ...............................................................................170 6.8 Mental health care .....................................................................173 6.9 Dental care ................................................................................176 7. Principal health care reforms ...........................................................179 7.1 The early 1990s ..........................................................................180 7.2 Mid-1990s ..................................................................................183 7.3 Late 1990s and early 21st century .............................................187 7.4 Current changes, further directions and challenges ...................190 8. Assessment of the health system .....................................................197 8.1 The stated objectives of the health system ................................197 8.2 The distribution of the health system’s costs and benefits across the population ..................................................................199 8.3 Efficiency of resource allocation in health care .........................202 8.4 Technical efficiency in the production of health care ................203 8.5 Quality of care ...........................................................................203 8.6 The contribution of the health system to health improvement .............................................................................205 9. Conclusions ......................................................................................207 10. Appendices ......................................................................................211 10.1 References ................................................................................211 10.2 Principal legislation .................................................................220 10.3 Useful web sites .......................................................................222 10.4 HiT methodology and production process ...............................224 10.5 About the authors .....................................................................227 iv Health systems in transition Estonia Preface he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development
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