Transcript Success story of Family Medicine: Estonia Margus Lember University of Tartu

Success story of Family
Medicine: Estonia
Margus Lember
University of Tartu
EURACT Council Member
Turku, 05.05.2006
Why changes?
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Low efficiency
Lack of coordination
Low comprehensiveness
Questionable continuity
Divided responsibility
Dissatisfaction among population
and among providers
Scope of services in 1992
Lember M, Kosunen E, Boerma W. Scand J Prim
Health Care 1998
B. Women`s problems in PHC
woman (50), lump in
breast
woman(20),confirming
pregnancy
woman(35), irregular
menstruation
woman (18), oral
contraception
Finnish
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10
20
30
40
50
60
70
80
90
100
Estonian
Procedures in PHC in 1992
53
cryotherapy of warts
0
94
excision of warts
0
65
applying a plaster cast
2
68
insertion of IUD
2
80
myringotomy eardrum
2
81
fundoscopy
2
84
maxillary sinus puncture
2
84
removal of sebaceous cyst from scalp
3
87
resection of ingrowing toenail
4
94
joint injection
5
90
removal of rusty spot from cornea
10
strapping an ankle
92
Finnish
11
87
setting up intravenous infusion
14
Estonian
98
wound suturing
26
0
10
20
30
40
50
60
70
80
90
100
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
1200
1000
996
864
800
628
600
404
400
907
676
462
290
200
0
146
63
162
63
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
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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.