success story of family medicine: estonia margus lember university of tartu euract council member...
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Success story of Family Medicine: Estonia
Margus LemberUniversity of Tartu
EURACT Council Member
Turku, 05.05.2006
Why changes?• Low efficiency
• Lack of coordination
• Low comprehensiveness
• Questionable continuity
• Divided responsibility
• Dissatisfaction among population and among providers
Scope of services in 1992Lember M, Kosunen E, Boerma W. Scand J Prim
Health Care 1998
0 10 20 30 40 50 60 70 80 90 100
woman (18), oralcontraception
woman(35), irregularmenstruation
woman(20),confirmingpregnancy
woman (50), lump in breast
B. Women`s problems in PHC
Finnish
Estonian
Procedures in PHC in 1992
26
98
1487
11
92
1090
5
94
4
87
3
84
2
84
281
2
80
2
68
265
0
94
0
53
0 10 20 30 40 50 60 70 80 90 100
wound suturing
setting up intravenous infusion
strapping an ankle
removal of rusty spot from cornea
joint injection
resection of ingrowing toenail
removal of sebaceous cyst from scalp
maxillary sinus puncture
fundoscopy
myringotomy eardrum
insertion of IUD
applying a plaster cast
excision of warts
cryotherapy of warts
Finnish
Estonian
How did DDs perceive themselves as doctors?Virjo I, Mattila K, Lember M, Kermes R, Pikk A,
Isokoski M. Att Primaria 1997;19:407-411
• Similarities between the Estonian district doctors and the Finnish general practitioners
• Social orientation
Favourable situation in 1990s
• primary care doctors- possibility to establish family medicine as a speciality and discipline
• specialists- improving quality of primary care (district doctors) would enable them to perform real specialists` work
• population- possibility to create an alternative health care to the previous system with its drawbacks
• politicians- possibility for a better control of rising health care costs; attracted by the novelty of the idea itself
How to get the first family doctors?
• Import?• Change of medical education for
young generation. But if the health system is not changed?
• Retraining of practicing doctors. • Who should change the system?• Does health care system influence
medical education or vice versa?
“Orthodox” approach in family medicine education
• GPs can be taught only by GPs in general practice
Specialists approach on teaching of family doctors:
• Specialists know best what family doctors must know and do; they have the best knowledge to be transferred to family doctors
International cooperation• WHO course in Tampere, Finland 1989• New Leuwenhorst Group in Tartu 1990
(M.Kvist, C.E Rudebeck, C.Arnold)• Contacts with SIMG, WONCA• Bilateral cooperation: Estonia-Finland
• Ideas, knowledge, inspiration
Chronology of development of Family
Medicine in Estonia• end 1980s, beginning 1990s- first ideas
spread in Estonia• 1991- postgraduate training of Family
Doctors; Society of Family Doctors founded, curriculum change at the University
• 1992- change of funding of health care; Department of Family Medicine at the University of Tartu
Ministerial decree from March, 1993
• Family doctor as a speciality
• Description of a family doctor
• 1995-Estonia /World Bank health project; Estonian Society of Family Doctors full member of WONCA
• 1994-96 unsuccessful preparation of Family Doctor`s law
Ministerial decree from April, 1997
• List system• Fixed number of practices• Family Doctor as independent
contractor• Combination in payment
(basic+capitation+fee-for-service+ bonuses)
• Gate-keeping (partial)
Ministerial decree from October, 1997
• Task description of family doctors
• Payment scheme for family doctors
• New contract since Jan. 1, 1998
15-year development• Training system according to EU
criteria
• Sufficient number of trained FD-s
• Legal aspects: job description, basic equipment, rooms, organization
• Stabile financing
Cumulative number of family doctors
63 63146 162
290
404462
628676
864 907996
0
200
400
600
800
1000
1200
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Was personal care by GPs illusion of the health care
reform?• all health problems• larger scope of services• patient lists• free choice of a doctor• personal care• gate-keeping function• emergency care• 24 h coverage
Estonian family doctors• 100% FD are independent
contractors with sick fund
• 56% FD have solopractices, 44% are working in groups
• 95% women
• GDP per capita (in 2002) 11,018 USD
• Health spending per capita 590 USD in 2002
• Health spending 5.3% of GDP
Contract• Acute cases: same day• Non-acute: within 3 working days
• Practice open: 8 hr every working day• Doctor`s surgery hours: minimum 20 hr
per week (depending on the list size)+ home visits+ other activities
Special features in Estonia
• Changes initiated inside the country, the international support came later;
• Political dynamics of the reforms was supportive
• Close collaboration between the family doctors, University, Ministry of social affairs and Health Insurance Fund
• Close cooperation between the leaders of family medicine and leaders of secondary and tertiary care specialities
• Enthusiasm of doctors• Timely using the “window for reforms” in
society• The leading role of the university• International collaboration.