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Reversing the birth rate trend in Estonia

Country: 
Estland
Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
(9)2007
Author(s): 
Agris Koppel, Ain Aaviksoo
Health Policy Issues: 
Finanzierung, Vergütung, Patientenbelange
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja ja ja nein nein

Abstract

Government has approved of the plan "Support for IVF 2007-2010" which aims to better the demographic situation in Estonia. The objective is to increase access to IVF services in Estonia and to raise the number of babies born as result of IVF to over 3% per year. The In Vitro Fertilization (IVF) has been used in Estonia since 1994. The first baby in the Baltic states conceived by IVF was born in Estonia in 1995. Government financially supports IVF since 2004.

Purpose of health policy or idea

The main purpose of the policy of implementation and compensation of IVF services to infertile families is to increase the birth rate in Estonia. The birth rate in Estonia has declined dramatically after 1990. While in 1988 there were 25 060 live births in Estonia the number dropped to 12 269 in 1998.

The policy is targeted to help people who are infertile - it is estimated that the rate of infertility is growing by 1-1,5% per year. The first step in this policy development  was the approval of the law of IVF and embryo protection in 1997. In 2004 the Estonian Health Insurance Fund started to cover the services for families. Women under 35 years of age were compensated for IVF treatment up to three times. In 2005 the maximum age limit  was raised to 40 years and in 2006 an additional reimbursement system for medicines used by patients during IVF treatment was implemented. In 2006 the government of Estonia approved of the plan "Support for IVF 2007-2010" which is part of a national strategy of public development policy. The plan will support IVF and development of new services with more than 15 million Euros in a four year period. The number of babies born after IVF is expected to increase to over 3.3% (500 babies) per year.

Graph: Age-specific birth rate Estonia 1989-2000

Source: Public health in Estonia 1999-2000 (www.sm.ee)

Main points

Main objectives

  • Increase the share of babies born after IVF
  • Increase the birth rate
  • Ensure access of families to IVF services
  • Ensure and increase the budget for IVF

 

Type of incentives

Mostly these incentives are non-financial as infertile families get services from IVF clinics, but also a financial reimbursement is paid for medicines consumed during the IVF process.

Groups affected

Infertile families, IVF providers, Society

 Suchhilfe

Characteristics of this policy

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

Implementing a national program to reverse the birth rate in a low birth-rate country like Estonia is not very innovative even expecting the good results from a wider use of IVF services. But there is a common will in society to increase the birth rate and ensure the persistence of the Estonian nation. Thus, a strong and high quality system of IVF services in Estonia has been created, while the public has been very supportive of all developments in the field.

Political and economic background

In summer 2006, the Estonian governement took resoponsiblity for developing a Master Plan of Supporting the Infertility Treatment 2007-2010, which was also included in the government's working plan for 2006. The basic objective of supporting infertility treatment was prepared in a collaboration of the Bureau of the Ministry of Population and the Ministry of Social Affairs. Also, the leading gynaecologists of Estonia were involved in the working process as consultants.

According to the document "Basics of Population Policy", supporting the infertility treatment is the method of highest priority in reversing the birth rate trend in Estonia.

Change based on an overall national health policy statement

In conjuction of National Program of Reproductive Health for 2000-2009

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

IVF treatment has been used in other parts of the world since 1978 and the first IVF procedures were performed in Estonia in 1994. In European countries, more than 850 IVF procedures per one million population are performed each year. In Nordic countries this number is even higher - 1500. In Estonia only 450 procedures per one million population are performed yearly.

The reversing of the declining trend in birth rate has been a continuous priority of political coalitions. After parliamentary elections in 2003 the Bureau of the Minister of Population was formed. The Minister and most employees in the Bureau are from the Reform Party. The work of the Bureau has been successful, as in 2006 the Master Plan of Support for the Infertility Treatment for 2007-2010 was developed.

A new center-right coalition started to work in April 2007 and still the aim of reversing the birth rate trend is agreed on by the coalition partners and part of the coalition contract.

Initiators of idea/main actors

  • Regierung: Government approved the plan
  • Parlament: Parliament approved the law of IVF and embryo protection in 1997
  • Leistungserbringer: First IVF were done in Tartu University Clinicum which became the centre for IVF for most patients from Baltic states
  • Patienten, Verbraucher: The share of infertile families is increasing 1-1,5% per year and the future need for IVF services is estimated to be 3 times higher than today
  • Privatwirtschaft, privater Sektor: There have been a lot of charity initiatives in the area of IVF, like in 1997 when 200.000 Euros were given by one person for families in need of IVF
  • Medien: Media has been very supportive in broadcasting on infertility and the concerns about the low birth rate in Estonia

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Else - The first IVF procedures in Estonia and the Baltic states were performed in 1994 at Tartu University Clinicum. The cost of IVF was covered by patients till 2004 when Estonian Health Insurance Fund started to partially reimburse the cost of IVF services.

Stakeholder positions

Society and the main stakeholders are highly supportive of the idea of reversing the birth rate trend in Estonia and also the method of IVF. There is practically no opposition to IVF support on the national level. Most stakeholder groups were and are involved in the preparation of legislative acts and national strategy. In 2003 a working group of experts within the Ministry of Social Affairs and representatives of other ministries was created. The working group with the Ministry of Social Affairs has been the leading force in developing the strategy of national support for IVF.

First, the law of IVF and embryo protection was launched in 1997 and modified in 2003 with the aim of broadening the rights of patients under the IVF program.

In 2006 government approved the Master Plan of Supporting the Infertility Treatement 2007-2010, the general objective of which is to increase the birth rate in Estonia within the next years.

Actors and positions

Description of actors and their positions
Regierung
Bureau of Minister of Populationsehr unterstützendsehr unterstützend stark dagegen
Ministry of Social Affairssehr unterstützendsehr unterstützend stark dagegen
Parlament
Reform Partysehr unterstützendsehr unterstützend stark dagegen
Party of Fatherlandsehr unterstützendsehr unterstützend stark dagegen
Leistungserbringer
Tartu University Clinicumsehr unterstützendsehr unterstützend stark dagegen
Private providerssehr unterstützendsehr unterstützend stark dagegen
Patienten, Verbraucher
Patient organisationssehr unterstützendunterstützend stark dagegen
Privatwirtschaft, privater Sektor
Individualssehr unterstützendunterstützend stark dagegen
Medien
Media organisationssehr unterstützendsehr unterstützend stark dagegen

Influences in policy making and legislation

The law of IVF and embryo protection came into force in 1997. The objective of this law was the regulation of IVF processes and embryo protection. In 2003 and 2006 the law was changed with the aim of detailing the terminology and extending IVF compensation mechanisms.

The development of the Master Plan of Supporting the Infertility Treatment 2007-2010 is one of the most important milestones in the evolvement of the IVF program in Estonia. Strategically the main objective is to guarantee the persistence of the Estonian nation by increasing the birth rate with the help of IVF. In developing the legislation and the master plan all important stakeholders were involved including the Bureau of the Minister of Population, the Ministry of Social Affairs, gynaecologists, patient groups and IVF providers. Consent to implement the Master Plan is very high, which is proved by the financial support for IVF providers and remuneration of medical costs for patients out of the national budget. The money is delivered through the Estonian Health Insurance Fund.

Legislative outcome

major changes

Actors and influence

Description of actors and their influence

Regierung
Bureau of Minister of Populationsehr großsehr groß kein
Ministry of Social Affairssehr großsehr groß kein
Parlament
Reform Partysehr großgroß kein
Party of Fatherlandsehr großgroß kein
Leistungserbringer
Tartu University Clinicumsehr großgroß kein
Private providerssehr großneutral kein
Patienten, Verbraucher
Patient organisationssehr großgering kein
Privatwirtschaft, privater Sektor
Individualssehr großgering kein
Medien
Media organisationssehr großneutral kein
Private providers, Media organisationsReform Party, Party of Fatherland, Tartu University ClinicumBureau of Minister of Population, Ministry of Social AffairsPatient organisations, Individuals

Positions and Influences at a glance

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

Adoption and implementation

The law of IVF and embryo protection came into force in 1997. The objectives of the law were regulation of the IVF process and embryo protection. In 1997-2003 only embryo transplant service was part of the list of health care services of the Estonian Health Insurance Fund (EHIF). During this period EHIF reimbursed 70% of the cost of three following services provided to patients younger than 35 years of age. All other costs (including the cost of medicines) were covered by the patient. In 1999 there was a charity project called  "Child to every family" implemented by an Estonian lady. The project supported infertile families with up to 200.000 Euros, but the main objective of the project was to turn more attention to infertility problems and the low birth rate in Estonia.

Supporting the IVF program is perceived by the government as one of the priority mechanisms to raise the birth rate to the level of the replacement rate of the Estonian population. Also, support for the IVF program is part of two national strategy documents - Implementation Plan of Basis of Population Policy 2005-2008 and National Program of Reproductive Health 2000-2009.

Previous governments have implemented a number of measures in the field of population policy in Estonia:

  • In January 2005 the age limit for reimbursement of IVF services was increased from 35 years to 40 years
  • In 2006 reimbursement of medicines used by patients during IVF programs was 600.000 Euros. In 2007 the amount of that budget has been increased up to 1.3 million Euros. 
  • Present results of the IVF program are comparable to European average results and gives almost 3.3% more births per year in Estonia. 

IVF procedures are done by four hospitals in Estonia, including two private obstetric clinics. The number of embryo transplants has increased from 279 in 2000 to 619 in 2005. The total budget for the implementation of the Master Plan of Supporting the Infertility Treatment 2007-2010 is 15.5 million Euros.

Monitoring and evaluation

So far there has been no evaluation or monitoring in the field of IVF. However, treatment guidelines have already been developed and for the coming years monitoring of quality and efficiency of IVF is planned every five years. Data from the Estonian Health Insurance Fund shows that the number of embryo transplants has increased almost 2.5 times since 2001 and there have been more than 200 children born after successful IVF.

Some statistics about IVF procedures during 2000-2005
Procedure Item 2000 2001 2002 2003 2004 2005
Embryo transplantation Units 279 287 274 287 405 619
  Cost, € 89,157 92,051 93,841 115,472 184,270 312,792
  Persons 252     251    
IVF Units         270 449
  Cost, €         130,891 216,798

* Data gathered from Estonian Health Insurance Fund financial reports 2000-2005

 

Expected outcome

The two objectives set up by the national strategy are: to increase the rate of children born after IVF and to increase the efficiency of IVF. The first target is achieved by increasing the compensation rate and the amount of services provided during IVF, which leads to a higher participation rate in IVF programs. The second objective is achieved by implementing infertility treatment guidelines, but also by introducing educational programs on reproductive health and sexually transmitted diseases in schools and youth groups.

Impact of this policy

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

One of the strategical objectives of the Master Plan is to increase the quality and cost-efficiency of IVF services, but so far there is no data available to assess quality and cost-efficiency of IVF services in Estonia.

References

Sources of Information

The authors very much appreciate the help and advice given by Ms Mari Loorens-Timmo from the Bureau of the Minister of Population, Mrs Helvi Tarien and Mrs Kristiina Kahur from the Estonian Health Insurance Fund.

 Other sources:

Bureau of the Minister of Population - all documents mentioned in the current report, in Estonian

Estonian Health Insurance Fund - compensation of medicines used during IVF program, in Estonian

Law of IVF and embryo protection - in Estonian

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo. "Reversing the birth rate trend in Estonia". Health Policy Monitor, April 2007. Available at http://www.hpm.org/survey/ee/a9/5