Identification of partners for DEAHL-BALTIC
1. Estonia (population size: 1.3) – if no other reference is indicated, then based on Kasekamp et al. (2023)
I. Organisation of the healthcare system:
• The Estonian health system is based on compulsory, solidarity-based insurance.
• Main actors: Agencies of the Ministry of Social Affairs (MoSA) (e.g. State Agency of Medicines, Health Board, National Institute for Health Development, Health and Welfare Information Systems Centre, the Estonian Health Insurance Fund (EHIF) (public independent body) and (predominantly publicly owned) hospitals under private regulation, mostly private primary health care units, various non-governmental organizations and professional associations.
• Responsibilities of main actors: The MoSA is responsible for health policy development, strategic planning, regulation and stewardship. Health Insurance Fund (EHIF). The EHIF is responsible for pooling public funds and purchasing health services from providers on a contractual basis, with an increasing role in financing services and central procurement of medicines. Local governments carry out public health activities and some of them also own hospitals, but their role in organization and funding of health services is minor. Large public hospitals provide inpatient and specialist outpatient care, while privately owned entities provide most primary and dental care and some specialist outpatient and long-term care. The independent family physicians is the first point of contact with the health system. Recent reforms aim to strengthen PHC by encouraging the establishment of multidisciplinary teams and promoting group practices.
• Long-term care of elderly: Mainly the responsibility of the family (often the women). In case there is no family or the family does not have the financial means to pay for long-term care, it is the obligation of the municipality organize this. In the larger cities or towns, there are public care hospitals and otherwise public paid private nursing home (Paat-Ahi G. & M. Masso, 2018)..
• The Estonian health system is centralized. Local municipalities carry out public health activities and some of them also own hospitals, but their role in organization and financing of health services is minor.
II. Health vulnerabilities and challenges:
There are large health inequalities related to socioeconomic background and region:
• Some regions of Estonia face an acute shortage of health professionals, particularly in family medicine and psychiatry. This shortage extends to nurses throughout the system. In 2021, Estonia had fewer doctors (343 per 100 000 inhabitants) and nurses (649 per 100 000 inhabitants) compared with the EU average.
• Accessibility to health care in Estonia is characterized by significant socioeconomic inequalities, where people with lower incomes are more likely to forgo care. Access to health care remains a challenge in Estonia, with around 4% of the population uninsured and more than 9% reporting unmet medical needs. Most of this unmet need is due to waiting lists (8.6%), which affect lower income groups more than higher income groups (11.2% versus 7.5%).
In some areas, the Estonian population are performing below EU average when it comes to certain diseases (see below).
To address fragmentation and poor coordination within the health care system, the MoSA and the EHIF have initiated efforts to improve patient pathways and test the implementation of bundled payment systems for these. Despite some successes, Estonia has yet to strengthen the coordination of care for people with hypertension and other cardiovascular diseases.
Issues such as the gap in population coverage, the growing shortage of health professionals, expanding prevention and early detection and ensuring timely access to quality care will need to be addressed in the coming years. In addition, concerns remain about the long-term sustainability of health system financing.
Some of the main challenges that they are facing relates to access to medical services in rural areas due to low population density. Therefore, they are investing in the development of long-distance diagnosis and monitoring.
III. Use of technology in the healthcare system:
Estonia makes extensive use of digital solutions for data management and exchange between providers. Notably, the implementation of the National e-booking system marked a significant step forward. However, standardization, interoperability and timely data exchange remain challenges in the field of e-health.
IV. Proposition of partners (as we have enough from academia, these are not mentioned here):
1) Ministries:
a. Innovation Team at the prime minister’s office and here Helelyn Tammsaar ((16) Helelyn Tammsaar | LinkedIn)
b. Ministry of Health
2) Firms: Cybernetica (Cybernetica)
3) (Public care hospitals/general hospitals in larger cities)
4) (Municipalities)
Estonia performs relatively well on digital healthcare (compared to the other Baltic countries and Poland) and at the same time, policy learning might be easier to facilitate. Strategically it might be interesting to combine a partner from the ministries (e.g. the Innovation Team) with a private firm.
2. Latvia (population size: 1.9) – based on Behmane et al. (2022) if no other reference
V. Organisation of the healthcare system:
• After regaining independence in 1991, Latvia experimented with a social health insurance type system. However, to overcome decentralization and fragmentation of the system, the National Health Service (NHS) was established in 2011 with universal population coverage. More recently, reforms in 2017 proposed the introduction of a Compulsory Health Insurance System, with the objective of increasing revenues for health, which links access to different health care services to the payment of social health insurance contributions. In June 2019 the implementation of this proposal was postponed. The statutory health care is financed via general and specific taxes.
• Main actors: The parliament (Saeima), the National Health Service (NHS), the Ministry of Health (MoH), local governments, hospitals (some owned by municipalities and larger university hospitals own by the state, some privately owned), public and private healthcare providers.
• Responsibilities of main actors: The parliament (Saeima) has a significant role in the development of national health policy. It approves both the national budget and the budget of the National Health Service (NHS). The Ministry of Health (MoH) is responsible for national health policy and the overall organization and functioning of the health system. The NHS institution implements state health policies, ensures the availability of health care services throughout the country, and is the main purchaser of publicly funded health services. Local governments are responsible for ensuring geographical accessibility, and, depending on budget and local priorities, maintain hospitals and long-term social care facilities. Local government is not involved in the direct payment of health care services, which is the responsibility of the NHS. Different ownership structures characterize health care provision in Latvia. Smaller hospitals and some larger regional hospitals are commonly owned by municipalities, while the larger hospitals (such as university hospitals) are owned by the state. Providers contracting with the NHS may be public or private; in the case of primary care they tend to be predominantly private; public or private in secondary care, and public in the case of tertiary care, with ownership concentrated at the state (national) or municipality (regional) level.
• Long term care for elderly: General social care institutions, financed by local governments, for older people and people with health problems of a physical nature, as well as orphaned children from 2 to 18 years of age.
• The Latvian health system is rather centralized, but with important local municipal actors. Local municipalities carry out public health activities and some of them also own hospitals.
VI. Health vulnerabilities and challenges:
There are large health inequalities related to socioeconomic background and region. The main causes of death in Latvia are diseases of the circulatory system, malignant neoplasms, external causes, and diseases of the digestive and respiratory systems. The top two causes are the same for both men and women.
Despite recent increases in spending, the health system remains underfunded and resources have to be allocated wisely. The proportion of out-of-pocket spending is among the highest in Europe, which is rooted in financial barriers and thus socioeconomic inequalities.
Latvia’s health outcomes should be considered within this context of limited health system resources. While life expectancy at birth in Latvia has increased since 2000, reaching 74.9 years in 2017, it remains among the lowest in the EU. Recent reforms have focused on improving access to services in rural/remote areas, increasing funding for health care services and tougher regulation of tobacco and alcohol. However, a number of longstanding unresolved problems still need to be addressed, including financial sustainability and low public funding, high levels of unmet need, high rates of preventable and treatable mortality, and challenges in both communicable and noncommunicable diseases.
To boost efficiency of the sector, Latvia has taken steps to improve the distribution of health care workers, and has substantially decreased the number of acute hospital beds. Health workers in Latvia are mainly concentrated in urban areas, leading to equity and accessibility issues, especially for rural populations. About 52% of the GP practices are based in the Greater Rīga Area, with primary care accessibility gradually decreasing with increasing distance from Rīga, and with a similar pattern for specialist care. In a comparative setting, nurses are lacking the most, the coverage of doctors is better.
Latvia’s Public Health Strategy 2014–2020: Target actions continue to include the promotion of healthy and active lifestyles, enhancing the quality and efficiency of health care services, emphasizing a person-centred health care approach, and developing integrated health care, as well as improving accessibility and reducing health inequalities.
VII. Use of technology in the healthcare system:
Since 2018, it was mandatory to use e-health system, but only the prescription system has been fully functioning (Mensikovs, 2020).
VIII. Proposition of partners (as we have enough from academia, these are not mentioned here):
1. Ministry/public health organization: The Ministry of Health (MoH), The National Health Service (NHS)
2. Public care hospitals for long-term care or general hospitals: middle size
3. Large municipality
4. (Start-up companies (good synergies between start ups and hospitals in Latvia)).
5. (Possibly for contact or further information: Lauma Muizniece (director at Latvian Council of Science, research interests such as innovation policy, R&D policy, technology transfer) (16) Lauma Muizniece, PhD | LinkedIn
Latvia performs relatively poorly concerning the implementation of digital healthcare (compared to Estonia and the rest of EU). Strategically and to facilitate policy learning and impact, then it might be interesting to combine a partner from the ministry/large municipality with a public care hospital.
3. Poland – if no other reference is indicated, then based on Sowada et al. (2022)
I. Organisation of the healthcare system:
• The Polish health system is based on social health insurance. Health insurance contributions (an earmarked payroll tax) are the main source of public health care funding, accounting for about 60% of current spending on health. These funds are allocated to the regional branches of the NFZ. Taxation accounts for about 10% of current expenditure and is used to finance outpatient medical emergency services, public health programmes and benefits for population groups exempt from paying contributions, among otherthings. Household private spending is the second most important source of funding, accounting for close to 30% of current health spending.
• Main actors: Ministry of Health, National Health Fund, regions, counties, municipalities, regional branches of the NFZ, hospitals, healthcare providers (public and private).
• Responsibilities of main actors: Planning is the responsibility of the central government, particularly the Minister of Health and the regions (voivodeships). The regions own the generally larger regional hospitals while counties own smaller county hospitals. Municipalities own some primary care practices although the majority of these practices are private. Municipalities are also responsible for certain public health tasks, but their health budgets are very limited. There is little coordination between these three administrative levels, which obstructs coordination of care and other activities. The regional branches of the NFZ are charged with the purchasing of services in their respective territories, which is open to both public and private providers. The basket of guaranteed services is set centrally and there is little scope to adapt purchasing to local needs. Most of primary health care and specialist outpatient care is provided in solo private or (usually small) group practices. Both can provide services under contracts with the NFZ or to private, self-paying patients. The majority of hospitals are public and most of them are owned by the territorial self-governments (regions and counties), with county hospitals providing less complex care than the tertiary-level hospitals owned by the voivodeships. Highly specialist clinics and institutes are owned by medical universities and the Ministry of Health.
• Long-term care is underdeveloped and relies on the family or private provisions.
• The Polish health system is fairly centralized with governance concentrated in the Ministry of Health and purchasing in the National Health Fund (NFZ). Some of these roles have been decentralized to the regions (16), counties (314) and municipalities (2477), and the regional branches of the NFZ.
II. Health vulnerabilities and challenges:
There are large health inequalities related to socioeconomic groups and elderly due to high levels of out of pocket payment. Rates of unmet needs is among the highest in Europe (Sowa-Kofta, 2018).
According to Eurostat data, the number of practicing doctors in Poland is 238 per 100 000 population, the lowest in the EU, and the number of nurses is also among the lowest (510 per 100 000 population). While national data report higher numbers, shortages of health workers still have been reported across the country, particularly in small counties around large cities and in rural areas.
Access to primary care is generally good, but patients living in rural areas have worse access compared with urban patients. Despite the overcapacity in the hospital sector, access to hospitals may also be limited by their uneven geographical distribution. Since medical equipment is mostly located in hospitals, access to diagnostics is also uneven and there is in general long waiting time.
Overreliance on hospital care relative to other forms of care and weak coordination between hospital and non-hospital care have been longstanding features of the Polish health system. Many patients could be effectively (and more cheaply) treated at lower levels of care and closer to their homes.
III. Use of technology in the healthcare system:
The use of teleconsultations has been increasing during recent years. It was high during the first two years of the COVID-19 pandemic; they have since remained widely used for initial consultations and patient triage within primary care. Since late 2021, they have been mandatory in certain situations, for example, when renewing prescriptions.
Recent implementation of e-health tools, such as electronic health records (implemented in 2019), e-prescriptions (2020) and e-referrals (2021) can support coordination of health services across providers and levels of care (a key challenge, see previous section). Although the number of procedures performed in day-care settings has been increasing, the share of one-day hospitalizations within the total number of hospitalizations remains much lower than the OECD average.
IV. Proposition of partners:
1) Hospitals
2) Regions
Poland performs relatively poorly concerning healthcare, including digital healthcare (compared to Estonia and the rest of EU). Strategically and to facilitate policy learning and impact, then it might be interesting to combine a partner from the region with a hospital.
Things to consider:
Most elderly seem to receive informal care in Estonia, Latvia and Poland – should we focus on this group, then we have to consider this.
Should we consider focusing on specific areas such as diagnostics and/or follow-up? Or a specific disease or number of diseases?
What Estonia, Latvia and Poland seem to have in common is to provide healthcare services in areas with low population density, sometimes due to distance to healthcare facilities and/or shortage of healthcare workers in rural areas. Should we consider addressing this gap?
References:
Behmane, D. et al. (2022): Latvia: health system summary 2022: Latvia: health system summary | European Observatory on Health Systems and Policies (who.int)
Kasekamp et al. (2023). Estonia - Health System Review 2023: Estonia: health system review 2023 (who.int)
Mensikovs, V. et al. (2020). ’Digitalization for increased Access to healthcare services’, Globalization and Business, Vol. 5, issue 10.
Paat-Ahi G. & M. Masso (2018). ESPN Thematic Report on Challenges in long-term care Estonia: EE_ESPN_thematic report on LTC.pdf
Sowada et al. (2022). Poland - Health system summary: Poland: health system summary | European Observatory on Health Systems and Policies (who.int)
Sowa-Kofta A. (2018). ESPN Thematic Report on Inequalities in access to healthcare Poland: PL_ESPN thematic report on access to healthcare.pdf