In Estonia, the government has decided where the hospitals in the national hospital network must be located. Considering the need to spread risks related to political and social stability, it has been established that not all hospitals should be located only in Tartu or Tallinn — the only cities where the population is still growing.

Primary emergency medical care or hospital treatment is also available in many of our small, charming towns. These hospitals operate under various legal forms — some are public limited companies, others are foundations — and their owners can be regional hospitals or local governments. The Ministry of Social Affairs oversees the healthcare provided by these hospitals and the Health Insurance Fund, which is their main source of financing, purchases healthcare services from them for insured individuals.

Every doctor's appointment or surgery is paid for at exactly the same rate to every hospital across the country, according to a price list approved by the government. And it is from this money alone that each hospital must manage its operations.

Has anyone ever heard that life in a remote area or small town is cheaper? More often, we hear that people and businesses are packing up and leaving because everything has become unreasonably expensive. Do the laws of economics somehow work differently in hospitals? Does anyone really believe that if big cities are short on doctors and nurses, there are plenty of them in Põlva in every specialty, happily working for lower wages?

In reality, it's quite the opposite. Salaries are usually higher to keep staff motivated and hospitals also bear heavy transportation costs in various forms. Every day I see invoices where partner companies add extra hours and surcharges to cover distances — usually starting from Tallinn — for technical maintenance or equipment transport.

As a result, many small hospitals are looking for and offering all sorts of additional services just to make ends meet — from renting out space, running laundries and cafeterias, to operating nursing homes or even baking pastries. None of this is forbidden, of course, but is it something that has been planned or considered in healthcare management?

One possible solution might again be to leave hospitals only in Tartu and Tallinn, with exceptions for the islands. But on the other hand, if we think about political and social security or inequality in access to essential services, would that really be a wise decision?

Over the years, experts have made various proposals regarding hospital locations. Implementing those ideas has not always gone smoothly and the political environment has sometimes changed. The COVID crisis and the war in Ukraine have forced the state to think differently. And so, day after day, decision-makers seem to bury their heads in the sand — hoping that patients in the periphery will somehow disappear or that owners will simply close their hospitals on their own.

As long as the hospital network's development plans are not just promises on paper and if we genuinely want to have modern hospitals with quality services and up-to-date medical equipment outside major cities, then when the need to reform healthcare financing arises — and few still doubt that it must — we must also consider these exceptions.

One option would be to add location-based coefficients to healthcare service payments or to move toward budget-based financing. In that case, every service would not have to be profitable to ensure survival, hospital management would not depend on patient volume and the state's total costs could ultimately even decrease.

With adequate funding, county hospitals could play a vital role in treating diseases that are the main causes of avoidable mortality. When deciding on financing, regional health indicators — such as healthy life expectancy — must be reviewed. And if those are lower than the national average, then ensuring sufficient resources for that county's hospital should clearly be seen as a matter of great importance.

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