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Revision of Hospital Reform

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Agris Koppel, Ain Aaviksoo
Health Policy Issues: 
Organisation/Integration des Systems, Politischer Kontext
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja nein nein nein nein nein nein


In April 2006 the Minister of Social Affairs launched the revision of Estonian Hospital Master Plan ? the cornerstone of hospital reform in Estonia. The revision of the plan is among others targeting smaller hospitals in less populated areas, which currently do not belong to the privileged short-list of 19 out of 52 hospitals, which is used for preferred contracting by health insurance and capital investments from EU structural funds.

Purpose of health policy or idea

The main purpose of the policy is to make amendments to the development plan of Estonian hospitals reform. In April the Minister of Social Affairs formed a commission consisting of representatives of the Ministry of Social Affairs, The work of Commission is based on political assumption that the planned hospital network is not proper and sufficient for Estonia in the light of accessibility and responsiveness of health care services.

Main points

Main objectives

  • Revised hospital master plan to achieve better  planning of health care services
  • Improved hospital network responsiveness to the public need

Type of incentives

The expected end-result will be redefined list of hospitals and definitions for different type of hospitals that forms the base for investments and health services contracts. No other incentives are foreseen as of today.


Characteristics of this policy

Innovationsgrad traditionell traditionell innovativ
Kontroversität unumstritten kontrovers kontrovers
Strukturelle Wirkung marginal neutral fundamental
Medienpräsenz sehr gering gering sehr hoch
Übertragbarkeit sehr systemabhängig recht systemabhängig systemneutral

The revision of the hospital network strategy documents is needed continuously, but it must base on clear needs and structure. Today the aim and expected outcomes of the work planned to do by the commission assembled by the Ministry of Social Affairs stay unclear. The volume of work and the time for that seem to be inadequate to reach for new knowledge of how to plan and regulate the hospital sector in

Political and economic background

HMP2015 and HMP2002 are strategic documents forming the conceptual and legal base for hospital reform, which is aiming at the reduction of the number of active care beds in In April 2005 the new new coalition government came into power. In their common governing programme there is statement about developing the principles of free patient choice of specialised care in Estonia and Europe to ensure higher accessibility to health care services. The Assistant Minister of Health of the Ministry of Social Affairs has referred to studies showing unequal access to hospital care depending on one's place of residence and consequently made also sentiments for the need of more flexible hospital system in Estonia.

There are no general policy documents that the current policy draws upon, and the main public reason for the initiation of the policy has been stated that the previous one was drafted 6 years ago and "that during this time structure of morbidity has changed, medical technology, knowledge about health care organisation, databases and level of analysis have improved".

Abovementioned typology of hospitals and the Master Plan behind it is used for long-term funding contracts by EHIF, but also for investments using EU structural funds money. Thus the idea has hidden agenda to broaden the circle of providers that are entitled to increased funding.

Change of government

The policy was directly introduced by new political power by populist left-lining party - Central Party (Keskerakond in Estonian).

Change based on an overall national health policy statement

The change is also motivated through the strategic goals of the Ministry of Social Affairs ? ?better health car eservices accessibility and quality?

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? ja nein nein nein nein nein nein

Origins of health policy idea

The idea has been in the air for years after the preparation of first Estonian Hospital Master Plan 2015, because there remained interest groups that were not satisfied with the decreasing volume and importance of Estonian hospital sector. Their argument goes that the diminishing number of hospital beds and concentrating of inpatient services affects the accessibility of inpatient care services in The main purpose of the revision of Estonian Hospital Master Plan 2015 is to change the set of principles and indicators used for planning of hospital sector, but also to propose the Ministry of Social affairs to change legislative acts which regulate the hospital sector.

The commission will work in cooperation with and under the control of the Ministry of Social Affairs and no professional analytical competence is used.

Previously there have been discussions about changing the remuneration system of hospitals and implementing the budget-based (or capitation-based) payment system instead of the contracting of volume and price of health care services.

Initiators of idea/main actors

  • Regierung
  • Leistungserbringer: Attitude varying from individual to individual
  • Kostenträger: position not clear
  • Politische Parteien: Keskerakond (Central Party)

Approach of idea

The approach of the idea is described as:
amended: The aim of commission is to revise the Estonian Hospital Master Plan 2015 which have been the basis for hospital network development during last 5 years. Also, changes in legislative acts are expected to take place is new strategical principles are accept

Stakeholder positions

Most of the stakeholders have expressed their confusion about the need for commission and the purpose of the Hospital Master Plan revision as the objectives are not very well clarified by the Ministry of Social Affairs. The general understanding is that there is needed only fine-tuning in planning of specialty services rather than change of basic principles of hospital development. The conflict is not on the level of structural planning of hospital sector but need for additional resources for hospital capital investments and development.

Actors and positions

Description of actors and their positions
Estonian Country Doctors Boardsehr unterstützendunterstützend stark dagegen
Estonian Hospital Associationsehr unterstützenddagegen stark dagegen
Estonian Medical Associationsehr unterstützenddagegen stark dagegen
Estonian Health Insurance Fundsehr unterstützendneutral stark dagegen
Politische Parteien
Minister of Social Affairssehr unterstützendsehr unterstützend stark dagegen

Influences in policy making and legislation

The aim of the revision of Estonian Hospital Master Plan 2015 is to change the principles for planning and regulating the hospital sector and it means that some legislative changes could be take place as result of the work. It can mainly affect the number and types of hospitals which are in hospital list approved by the Government, but also it can change the requirements for hospital renovation and building.

Legislative outcome


Actors and influence

Description of actors and their influence

Estonian Country Doctors Boardsehr großgering kein
Estonian Hospital Associationsehr großgroß kein
Estonian Medical Associationsehr großgroß kein
Estonian Health Insurance Fundsehr großgroß kein
Politische Parteien
Minister of Social Affairssehr großgroß kein
Minister of Social AffairsEstonian Country Doctors BoardEstonian Health Insurance FundEstonian Hospital Association, Estonian Medical Association

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The time-frame of the commission work is very short and it is assumed that the process will not succeed by the autumn 2006 as wanted by the Ministry of Social Affairs. The crucial constrain is that the hospital network is very complex and just some descriptive overview based on cross-sectional aggregate statistical do not give right perspective. Also, as the problem to be solved has not been defined it is difficult to come to common agreement on the solution or proposed changes by different stakeholders.

However, the committe is supposed to meet 2-3 times and analytical department of the Ministry of Social Affairs is providing basic analysis for decision-making. The results are plenned to be presented on an annual Health Care Conference in November 2006. It has not been stated, but can be assumed, that about the same time, the issue should be in the Government for deciding.

Currently there are politically difficult times for controversial decisions. Presidential elections take place in August 2006 and next parliamentary elections are due in March 2007.

Monitoring and evaluation

The process of revision of Estonian health care strategy documentation is not set in place and it is not the aim of this activities also.

Expected outcome

As rational objectives of the revision of Estonian Hospital Master Plan 2015 have not been defined then it would be rather difficult to evaluate the outcome or impact of the commission work. The initiative has potential for strong long-term effects if the final outcome of it will be broadening of the circle of hospitals eligible for capital investments using money from EU structural funds. As the Government Regulation on hospital types is also the basis for prefernetial purchasing of active care from listed hospitals by EHIF, the change in this list also may influence the one driver of restructuring active care beds into long-term care beds in rural areas.

The possible results are changes in principles of planning hospital network and changes in status of some hospitals in Estonia. But if it improves or affects health care services accessibility, or quality or has any effects on costs of health care services, is really to early to assume.

Impact of this policy

Qualität kaum Einfluss wenig Einfluss starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch

The effect on cost-efficiency can be decided once the decisions based on the work of the Commission will be made. At the health care system level both increase and reduction in hospital care costs are possible scenarios based on the available information.

Although one goal behind the idea is more equitably developed hospital network, it is possible that the harmonization will be towards lower common denominator of hsopitals, because very small counties cannot offer necessary patient pool to maintain adequate quality level in the long run.


Sources of Information

  • The strategic goals of the Ministry of Social Affairs - "better health car eservices accessibility and quality":
  •  Ministry of Social Affairs press release from April 18, 2006 "Updating of Estonian Hospital Master Plan 2015 is started",
  • Interview with the head of Estonian Hospital Association and CEO of Parnu Hospital, dr Urmas Sule

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo. "Revision of Hospital Reform". Health Policy Monitor, April 2006. Available at