Health Systems Dialogues

Anuradha Katyal
Deck overview
01 Country profile

02 Economic evolution

03 System’s analysis

04 Health Systems
Building Blocks

05 Recommendations for
India
Country profile
Population
Estonia is the smallest of the 1.3 million
Baltic States, the three High-income country
republics on the east coast of European Union (since 2004)
the Baltic Sea. The country is
situated on the eastern border Health expenditures (2016)
6.7% of GDP
of the EU, bordered by the
Russian Federation to the east Per person (2019)

and Latvia to the south and 2507 USD

with close proximity to Finland Public expenditure
(Fig. 1.1). It covers an area of 75.7% of THE
approximately 45,339 km2,
which is slightly larger than Health insurance
65.0% of THE
Denmark or the Netherlands,
for example, however with OOPE
considerably lower population 22.7% of THE
density. Estonian Health Insurance Fund (EHIF) is a single payer
Social health insurance system since 1992
Reforms and evolution of the system

Post WWII Estonia was occupied by

USSR and regained independence in
1991

Estonia embarked on economic

reforms and by 1993 the country had
succeeded in reversing the declining
trend of its GDP

They developed a conservative fiscal

policy combined with a liberal
economic policy

They have a simple taxation system

(26% flat tax)

Ease of Doing Business index by the

World Bank (2019) sets Estonia at the
16th position, plus a strong e-Estonia
policy
Health System Analysis

Public Healthcare Systems Overview

Monopsony financial 95% Covered by monetary

system benefits and curative and
Rank in progress on SDGs preventive care
10 (2016)
UN E-Government Survey
3
of 163 countries

2020*
Healthcare Access &
81 Quality Index Score
maximum: 100 (2015)**

**The Healthcare Access and Quality (HAQ) Index is measured *Index based on efforts to provide effective,
on a scale from 0 (worst) to 100 (best) based on death rates accountable and inclusive digital services
from 32 causes of death that could be avoided by timely and
effective medical care (also known as 'amenable mortality').
Building Blocks of
WHO
Healthcare governance

Ministry of Social Affairs

EHIF
National Institute
Health State Agency
for Health
Board of Medicines
Development

Contracts

Health care providers,

private law, public or private
ownership
Healthcare governance

Tripartite supervisory board of EHIF

5 state representatives
▪ Minister of Health and Labor, Minister of Finance and Chairman of the
Parliamentary Committee of Social Affairs (ex officio)
▪ 1 member or parliament (nominated by the Parliament)
▪ 1 public servant from Ministry of Social Affairs (nominated by the Government)
5 employer and 5 beneficiary representatives
▪ Nominated by Government according to the proposal made by representing
organizations
Supervisory Board design is expected to prevent conflict of interest
▪ Supervisory Board decisions are public
 Evolution of Health Insurance
First sickness funds in 1913
Re-established regional non-
competing sickness funds in
1991/92 (22 in total)
Central sickness fund to
coordinate regional funds in
1994
Estonian Health Insurance Fund
in 2001, Currently with 4
regional departments
Estonian Health Insurance Fund (EHIF)
is a single payer
EHIF pools most of public funds
The main source of revenues 13% payroll tax
paid by employers
Coverage with health insurance 94-96% of
population
EHIF operates as public independent
legal entity
Founded in public interest by separate act
General public service regulation does not
apply to EHIF
Governed by Supervisory Board chaired by
Minister of Health and Labor
Contractual Mechanisms

Changes in health
EHIF’s 4-year budget service prices and
planning principles benefit package
and EHIF’s 4-year
development plan
Annual (by 6
months) capped
Negotiations cost and volume Quarterly contract,
Pooling EHIF’s Selection about contracts; 5- queue and budget
in EHIF annual of contract year framework monitoring and
budget partners volumes contracts utilization review

Adjustments of
Demand/need Framework contract contract if
assessment by conditions negotiated and necessary
specialities agreed among EHIF and
(running and next year Estonian Hospital Union or
perspective) Estonian Society of Family
Physicians
Service Delivery

Establishment of system (objectives and principles) –

Parliament
▪ Primary Recent pilots ▪ Piloting
Contributions definition and coverage (eligibility) – Selected partners
integrated
care:
Parliament 7% Revision of care model
capitation,
FFS, P4P P4P to (hospital+PHC
Co-payments –general regulation by Parliament; actual incentivize center)
co-payments by providers General hospitals ▪ Outpatient more
12% specialist adherence ▪ Pay for high-
care: FFS to the risk patient
Delivery package – general regulation by Parliament; guidelines
actual benefit package by Government management
▪ Inpatient
specialist ▪ New PHC ▪ Episode
Regional hospitals
Provider payment methods and Prices –Government; price care: DRG,
52% Centers based
calculation methodology by Ministry of Social Affairs per diem, payment payment
FFS, model
Central hospitals
Contracting – basic principles by Parliament; specific
29% preparednes
principles by Supervisory Board of EHIF s fee ▪ Global
budget
(pilot in
Waiting time limits –Supervisory Board; for primary care rural
by Ministry of Social Affairs hospital)

Budget – forecast by MoF; budget position by Parliament

as part of State Budget; in detail by Supervisory Board
Information Systems

The Estonian e-health system is unique as it is national level, integrates defined healthcare data from all
healthcare providers, and provides an overview of each resident's health status from birth to death.

The significant change management issues that digitalization brings to healthcare are always a challenge.
Observations and difficulties that were related to Estonian e-health system were (and are) as follows:

• Data quality and secondary data usage remain difficult.

• The general acceptance of hospital personnel to share medical data with patients via patient portal is
problematic.
• Users' security and electronic authentication must be given special consideration.
• People are not interested in medical data; they are interested in services.
Key “layers” of the EHR

The data layer consists of the data repositories for storing the medical
documents and images.

The data transfer layer provides a secure Internet-based infrastructure for

data exchange both for citizens and healthcare providers.

The developing and open-ended application layer is to provide services for

different parties (citizens, healthcare providers, government authorities,
policy makers, etc.) according to their demands now and in the future.
Governance of e-Health
Lessons for India

Single-payer model has been proven to work well in Estonia

Strong institutional framework with governance structure
Broader revenue base will increase financial sustainability

Financial incentives across different levels of care are important to achieve UHC
Blending payment methods enables to mitigate negative side-effects of single payment method
Strategic purchasing in much more than payment methods
Health financing reforms have to be aligned with broader health service delivery reforms
Good quality data is a precondition for monitoring the performance of providers

Developing e-Health was not in isolation but a oart of large e-Estonia initiative. The main success
factors for the e-health system in Estonia are clear governance, legal clarity, a mature
ecosystem, agreement about access rights, and standardization of medical data and data
exchange rules.
Coming up…

Quality of healthcare
Human Resources of Health
Journey to Universal Health Coverage
National Health Plan
Thank you