The Estonian Republic is a country in the Northern Europe, situated on the north-eastern coast of the Baltic Sea and, bordering the Gulf of Finland and the Gulf of Riga. Geographically the country is divided into 15 counties. Estonia has been a member of the European Union since 1st May 2004.
- The population of Estonia is more than 1.300 000 people
- The gender distribution is 54% female and 46% male
- The economically active population comprises 67% (16 to 65 years)
- Children make up 18% of the population (up to 15 years)
- Senior citizens constitute 18% of the population
- The average life expectancy for women is 81.5 years, for men – 72.3 years
- Residents of Estonia by ethnicity are: 69% Estonians, 25% Russians, 2% Ukrainians, and other nationalities (Finns, Belorussians, Latvians, Jews, Lithuanians, Poles, and others)
- The official language is Estonian (in addition to this the Russian language is widespread, especially in the north-east of Estonia and in Tallinn)
The foundation of the current health care system in Estonia was laid down in 1992, after the restoration of independence. The Swedish healthcare system was used as a prototype. The Estonian health care system is based on the principle of compulsory solidarity and general access to medical services.
The Ministry of Social Affairs is responsible for management and general oversight of the system. The total expenditure on health amounts to 5.8% of GDP. Hospitals and private property related to the public sector, legal medical institutions of the first level, as well as some non-governmental organizations and professional associations are part of the complex organizational structure of the health system. Basic regulations and initiatives to prevent losses related to health are, based on the Law of the organization of medical services and on the Law of Obligations Act.
The main source of health financing in Estonia is an independent public-law institution of the Health Insurance Fund, the budget of which is included in the state budget. To a lesser extent some items of expenditure are financed through the state treasury.
Medical licensing of the hospitals is governed by the Department of Health. The license is based on the type of hospitals and takes into account the availability of staff, the number of hospital beds, available equipment, which in turn are stipulated by the law. Funding is provided through a contract with the health insurance fund, which takes into account the type of hospital and permission to work.
After the restoration of independence, the structure of the hospitals was changed – smaller hospitals were closed and / or integrated into bigger ones. Some parts of the hospitals were redesigned into nursing care hospitals. Private medicine has been permitted in Estonia since 1992. At present, there are several types of hospitals in Estonia: regional, central, general hospitals, local clinics, private hospitals, rehabilitation centers and nursing care hospitals. Private clinics don’t take more than 5% of the market of all medical services.
The boundary between public and private medicine is blurred, because:
– There are no government medical institutions in the country;
– Large public hospitals are joint-stock companies or public organizations that belong to the municipalities, being legally private entities;
– Many private clinics have a contract with the Estonian Health Insurance Fund for the provision of medical services.
In private hospitals, all medical services are paid for. In public hospital the payment for medical services is covered by the Health Insurance Fund and indirectly by patients through the social tax, which is payable by the working population.
The Estonian Pain Society was established in 1990 as a non-profit and non government organisation. At the same time, it established contacts with the EFIC by joining the organization.
At the moment, there are more than 75 active members in the Estonian Pain Society. It mainly consists of anesthesiologists and neurologists, and also of medical nurses working in the field of pain management and nursing care. It also includes palliative medicine specialists (physicians and nurses).
The administrative structure of the Estonian Pain Society is the following: the President and the Board, who are elected by all members. Nurses and physicians can enter the society freely. The Society Board consists of representatives of Estonia’s main hospitals. The Estonian Pain Society consists of doctors and nurses from different specialties such as anesthesiology, neurology, rehabilitation treatment, surgery, oncology, etc.
The main objective of the Society is to create optimal conditions for professional education and practice in the pain treatment. The activities of the society also aim at familiarizing health care professionals and general public with the problems of people suffering from pain.
The Estonian Pain Society was founded in 1990 by Professor of Neurology Rein Zupping, who also organized the first Pain Clinic in Estonia. Professor Rein Zupping made an enormous contribution to the development of cooperation with the international organizations in the areas of neurology and pain management. He was also the first president of the Estonian Pain Society.
The next president was Ursula Koorits, who was an anesthesiologist and who continued active development of the society and participated in the creation of the first pain management standards and guidelines.
At the moment, the president of the Estonian Pain Society is Dr. Boris Gabovich, who developed the first education course for the training of specialists in the field. Contributions to the society were also made by Dr. Yuri Alex Kolesnikov, who defended the first dissertation devoted to the pain treatment on the territory of the former USSR.
The Board of the Estonian Pain Society consists of six members who are practitioners in the pain management fields. The Board members are elected and they represent the main hospitals in Estonia, where there are offices or pain management services.
At the moment, the number of the public members is about 76. The number of members is dynamically changing due to the fact that some doctors stop the practice, and some migrate to other countries, new specialists are joining too.
Unfortunately, the selected specialty or subspecialty for the pain management doctors and nurses in Estonia does not exist. But there is a list of doctors with additional competence in pain treatment, who have an opportunity to treat pain and prescribe strong opioids. The list is made and changed by the Estonian Pain Society and submited by to the Ministry of Social Affairs. Because there is no Pain managment specialty in Estonia, the main specialties of the doctors involved in the pain treatment are: anesthesiologists and neurologists, but there are also other doctors: surgeons, oncologists and physiotherapists.
Registration of the new members of the society takes place through the web site with the membership fee payment. It can be any doctor and nurse who is interested in studying and treating pain. The Estonian Pain Society creates conditions for training and professional development for these professionals.
At the moment, there are about 25 – 30 doctors working in outpatient pain departments and pain offices in Estonia. These offices and clinics are uniformly distributed in the large hospitals of the county with a calculation that from any point in Estonia and from each patient there is no more than 50 km to the pain management doctor. This helps to comply with the principle that analgesia should be accessible for all patients. The admission and treatment of patients is conducted in eight public and one private pain treatment offices. Both out-patient and in-patient medical treatment are provided in clinics and hospidal departments. The emphasis is on an integrated approach that includes pharmacological and, non-pharmacological therapies, invasive and rehabilitation techniques. Separately the Estonian Headache Society exist that, which cooperates and closely communicates with the Pain Society.
Currently, there is almost no research work in the area of pain management in Estonia. At the moment, two major studies are underway: in the areas of pain genetics and pharmacology, under the direction of Dr. Yuri Alex Kolesnikov and on the topic of opioid obstipation.
Despite the lack of specialty in the country, the Estonian Pain Society has developed a system of additional training for all physicians interested in pain treatment. The system includes the following:
- theoretical lectures at the university and a practical one-month course at one of the central hospitals, mainly for anesthesiologists, but also available for other doctors. Due to a small number of experts, the focus is on the individual training with an internship in different countries of the European Union.
- Additionally there are lectures on various topics of pain treatment for doctors and nurses. The lectures deal with the following topics: chronic pain, cancer pain, neuropathic pain, acute pain, perioperative analgesia, opioids, and so on
Further objectives of the Pain Society ares:
- Recognition of sub-specialty for physicians and for nurses.
- Separate funding from the Estonian Health Insurance Fund (currently there is no separate funding, it is carried out on the residual principle and basic patient’s disease, such as back pain – neurology, pain in the joints – orthopedics).
- Introduction of separate training system at the University followed by residency.
- Legislation improvement concerning legal opiate trafficking.
- Development of the national guidelines for the treatment of various pain syndromes. At the moment, there is only one national guideline in perioperative analgesia.
- Expansion of invasive pain management methods.
The existing achievements in the last five years include: three changes in the legislation, optimizing prescribing rules. They include a 100 percent discount on strong opioids for patients with non-oncological and chronic pain; permission for GPs to primary prescribe strong opioids for patients with oncologic pain syndromes. These changes are the result of lengthy negotiations with the Ministry of Social Affairs.
Unfortunately due to the lack of adjustment at the state level, the financing of the residual principle and undeveloped private practice in pain management, innovation is delayed. However, the society is constantly considering options for further development and patient care. At the moment, the focus is on educational programs for doctors and patients, which may further contribute to a more active development of the Estonian Pain Society.