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Experts: Hospital reform seeking balance between effectiveness and policy

Magdaleena Hospital, part of East Tallinn Central Hospital (ITK).
Magdaleena Hospital, part of East Tallinn Central Hospital (ITK). Source: Priit Mürk/ERR

Responding to Minister of Health Riina Sikkut's (SDE) position that smaller hospitals and their maternity wards should not be closed, healthcare experts said that the ministry is making decisions taking effectiveness and policy options into consideration.

Despite historically low birth rates, the Ministry of Social Affairs has no plans to close smaller hospitals' maternity wards or completely shut down a single county hospital, Minister of Health Riina Sikkut (SDE) said during Vikerraadio's morning program. Sikkut likewise said that Estonia's hospital system must mitigate how Tallinn-centric it is, but that the state nonetheless has to ensure that Tallinn Hospital will be built.

Commenting on Sikkut's positions, Jaanus Pikani, head of the expert group behind the ministry's commissioned study "Estonian hospital network development plan through 2040," told ERR that his analysis has likewise shown that county hospitals should be closed.

"We're moreso talking about the reprofiling of hospitals as needed," Pikani said. "To ensure that the service provided is relevant to needs. That is why we've also proposed the concept of a community hospital. The minister tried to hint obliquely in her interview as well that each hospital should find its own profile, but it's clear that there also has to be enough demand for profiled activities to warrant a sufficient load that would in turn ensure the quality of care provided."

The fact that doctors move from one hospital to another may not provide the necessary load for the operation of a hospital, he said.

"And you can't really provide specialized medical care bare-handed anymore these days either," he continued. "Modern specialized medical care requires equipment – usually quite expensive – and the effective use of this equipment means that there must be enough people who need this service."

According to the expert group chief, based on Statistics Estonia population projections, the inevitable reality is still that people are concentrating in Tallinn and Tartu while the population in other counties decreases.

"But with Tallinn Hospital, the question is – what are our priorities?" he asked. "What's a more pressing issue – developing primary care, or once again investing in concrete? The current state of [our] hospitals likewise urgently requires this kind of massive investment. It's quite obvious that the state's investment and administrative capacity has its limit – if you invest in something, then money will end up short somewhere else. I suppose this is a policy decision in a situation where the Estonian Health Insurance Fund (EHIF) is already allegedly short €100-150 million today."

Pikani likewise pointed out the fact that in developed countries, the population is aging and the share of people with chronic illnesses is increasing.

"Many of them have multiple chronic illnesses at once," he explained. "These people may only need specialist care due to their illnesses maybe once or twice a year. The emphasis is first and foremost on primary, nursing and social care. Rather, they need support during a flareup, and maybe a short-term hospital stay close to home – the provision of which is the idea behind a community hospital."

This would also mean a significantly more robust and capable primary level and cooperation between different levels of medical care as well as social care, he added.

Expert group chief: Few deliveries reduces hospital's capabilities

The closure of smaller hospitals' maternity wards is a "very, very difficult policy decision," Pikani said.

"If you look at the opposition and the response solicited by the closure of the maternity wards in Valga and Põlva," he recalled. "Childbirth falls under gynecological services, which means that there isn't just one specific profile of employees involved – it also requires anesthesiologists, nurses, midwives. Whether emergency specialized medical care in surgery and in gynecology is provided at Estonia's smaller hospitals or not is a complex issue."

He noted that Haapsalu hasn't had a maternity ward of its own for 20 years already, and has worked out quite well, as Tallinn is only 100 kilometers away.

"We know that below a certain threshold – it's even said that below 500 deliveries at one hospital – the safety of childbirth may be jeopardized," the healthcare expert explained.

"Other countries' experiences have shown as much as well," he continued. "In the Netherlands, for example, neonatal mortality rose when there were many service providers but very low numbers of deliveries at a hospital. Estonia has a very good record in terms of reducing the neonatal mortality rate; it is safe to give birth here. But will this last if the number of deliveries in maternity wards continues to decline?"

According to Pikani, in medicine you have to look primarily at the long-term, bearing the age and location of the population in mind, as currently one-fifth of Estonia's population is over the age of 65, but Statistics Estonia predicts this age group will increase to 26 percent of the overall population by 2040, which will mean the need for more healthcare services.

"I question whether we'll be able to guarantee access to healthcare at today's level without significant changes in healthcare, which should consist primarily of a substantial increase in primary healthcare capacity, the development of digital services and the integration of healthcare and social care services," he said.

WHO adviser: Hospital mergers common

Likewise commenting on Sikkut's positions regarding hospitals, Toomas Palu, the World Health Organization's (WHO) health systems and financing adviser in Ukraine, said that on one hand, the hospital network should be organized with regard to effectiveness and quality of care, but on the other hand, policy arguments play a role as well – for example, the fact that county hospitals are often vital local employers in their communities.

"Policymakers have to make decisions between these two positions," he acknowledged.

Regarding plans to build the proposed Tallinn Hospital, according to Palu, it's a widespread practice elsewhere in the world for hospitals in old, outdated buildings to merge and move into new hospital buildings together.

"Often these hospitals are no longer in the city center, but specifically in the suburbs," he pointed out. "Pärnu Hospital was also a good example of this direction."

He noted that some hospital buildings in Tallinn have certainly outlived their time.

"At the time [in the 2000s], the Swedes' development plan for Estonia's hospital network recommended Tallinn have three hospitals," the adviser recalled. "Four public hospitals remained in Tallinn at the time; the children's hospital remained separately as well. Now it's up to the city to decide how they're going to consolidate two hospitals. I think it's also important what will happen with the old buildings and departments."

Regarding healthcare financing preferences, Palu said that there are two sides to the money issue.

"One is investments, which is putting money into new things," he explained. "Tallinn Hospital is a very big investment. And the other thing is now meeting the population's existing healthcare needs and investing in people's health, year in and year out. These have to be considered separately."

The WHO adviser believes that the medical network's primary level could be doing a lot more to maintain people's health and address chronic illness. This would also reduce the need for hospital care.

He added that the country needs an optimal hospital network.

"One that takes the needs of its population and economies of scale into account," Palu explained. "Meaning there are sufficient volumes to make running a hospital worthwhile, because hospital services require support services as well: labs and digital devices and high-tech operating rooms that you can't just sprinkle across Estonia."

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Editor: Aili Vahtla

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