Social inequalities in the use of health care services after 8 years of health care reforms – a comparative study of the Baltic countries

Objective:  In nineties, Estonia, Latvia and Lithuania have implemented a wide range of changes to health systems. The objective of this paper was to assess social inequalities in utilisation of, and access to, health care services in the late nineties. Methods:  The comparative NORBALT Survey conducted in 1999 is used. Direct standardization and logistic regression was applied to analyse primary, out-patient and hospital care utilisation, and self reported financial barriers, by socio-demographic and geographical variables. Results:  In all three countries social inequalities in utilization were large for out-patient specialist care, smaller or absent with regards to primary care or to hospitalisations. Inequalities were large and consistent in relationship to household income, less so in relationship to educational level. Inequalities in utilization of care were larger in Latvia as well in the self reported barriers to health care in absolute and relative terms were larger. Conclusions:  After 8 years of reforms, important pro-rich inequalities in the use of health services existed. In Latvia, these inequalities were largest, possibly due to higher ratio of cost sharing as compared to Estonia and Lithuania. Submitted: 15 February 2008; revised: 16 July 2008, 04 October 2008; accepted: 08 October 2008     

Trends in the magnitude of educational inequalities in health in Estonia, Latvia, Lithuania and Finland during 1994-2004

BACKGROUND: Socioeconomic inequalities in health in the Baltic countries are possibly increasing due to concomitant pressures. This study compared time trends from 1994 to 2004 in the pattern and magnitude of educational inequalities in health in Estonia, Latvia, Lithuania and Finland. METHODS: The data were gathered from cross-sectional postal surveys of the Finbalt project, conducted every second year since 1994 on adult populations (aged 20-64 years) in Estonia (n=9049), Latvia (n=7685), Lithuania (n=11,634) and Finland (n=18,821). Three self-reported health indicators were used: (i) less than good perceived health, (ii) diagnosed diseases, and (iii) symptoms. RESULTS: The existing educational inequalities in health in three Baltic countries and Finland remained generally stable over time from 1994 to 2004. Also, the overall prevalence of all three health indicators was generally stable, but in the Baltic countries improvement in perceived health was mainly found among the better-educated men and women. Diagnosed diseases increased in the Baltic countries, except Lithuania, where diseases decreased among the better-educated women. Symptoms increased among the better-educated Estonian and Finnish women. CONCLUSIONS: The period from 1994 to 2004 of relative stabilization since the worst conditions of the social transition has not been followed by notable changes in self-reported health, and this appears to be the situation across all educational groups in the Baltic countries. While health inequalities did not markedly change, substantial inequalities do remain, and there were indications of favourable developments mainly among the better-educated respondents. The factors contributing towards increasing health inequalities may only be visible in the future.     

Physical inactivity in the Baltic countries

BACKGROUND: Physical inactivity is a known risk factor for heart disease and obesity, two major health problems in the Baltic Republics. This study examined patterns of physical activity level in these countries, and correlates of leisure-time sedentary behavior. METHODS: Data from three national surveys of adults conducted in Estonia, Latvia, and Lithuania in 1997 were used. Respondents who provided information on their activity level were included in this study (Estonia: n = 2,018; Latvia: n = 2,303; Lithuania: n = 2,140). RESULTS: One in three Estonians and one in five Latvians and Lithuanians had a low physical activity level at work. Half the respondents (Lithuania: 60%, Latvia: 52%, Estonia: 43%) participated only in sedentary activities during their leisure time. Leisure-time sedentarity was inversely related to education level in men and women and with income in men. It was also associated with smoking in men and with inadequate vegetable intake in men and women. CONCLUSIONS: Sedentary behavior during leisure time should be a public health issue in the Baltic Republics. Health promotion strategies aiming at increasing leisure-time physical activity level will need to target the general population, but particularly individuals from lower socioeconomic strata.     

Changing social variations in self-assessed health in times of transition? The Baltic States 1994-1999

BACKGROUND: Dramatic social changes took place in the Baltic States (Estonia, Latvia and Lithuania) in the 1990s. This study investigates the extent to which social variations in self-assessed health changed during that period. METHODS: Norbalt Living Conditions Survey I (1994) and II (1999) random population-based samples in Estonia, Latvia and Lithuania were analysed. Associations of self-assessed health with six social dimensions (education, economic activity, car ownership, number of rooms, ethnicity and residence) were studied for males and females aged 25-74 years (n = 16 970). RESULTS: Substantial and significant associations with poor health were found for education, economic activity, car ownership and, to a lesser extent, number of rooms. Ethnic differences were found only among women in Estonia. By and large, social variations in health were comparable for most indicators between the three countries. Differences in self-assessed health were stable between 1994 and 1999, except for the relatively worse position of the economically non-active in 1999. CONCLUSIONS: Substantial social inequalities in self-assessed poor health exist in the Baltic States. Despite dramatic social changes taking place, social variations in self-assessed health have been rather stable in the second half of the 1990s. The economically non-active seem to have become more disadvantaged.     

Macronutrient and food intake in the Baltic republics

OBJECTIVE: The objective of this study was to describe mean macronutrient and food intakes in the Baltic republics, with a particular focus on fat, vegetable and fruit consumption. DESIGN: Cross-sectional study. SETTING: Data from surveys conducted in Estonia, Latvia and Lithuania in the summer of 1997 were used. Information was collected using a 24 h recall of dietary intake and an interviewer-administered questionnaire. SUBJECTS: Representative national samples of adults were selected. All those with information from the dietary recall were included in the study (Estonia: n = 2015; Latvia: n = 2300; Lithuania: n = 2094). RESULTS: The mean proportion of energy from fat was high in each country, but particularly in Lithuania (44%) and Latvia (42%) compared with Estonia (36%). In contrast, percentage energy from carbohydrate, protein and alcohol was higher in Estonia. Mean protein intake was generally sufficient if not high in some population sub-groups. Median vegetable intakes were very low (<200 g/day) in each country, particularly in Latvia. While 78% of the Lithuanian respondents consumed vegetables daily, this was the case in only 60% of the Latvian and 48% of the Estonian respondents. CONCLUSIONS: This study suggests that there is a pressing need to replace high-fat energy dense foods by foods rich in complex carbohydrates and dietary fibre, such as vegetables and fruits, in the Baltic republics. This could provide the populations with a reduced risk and increased protection against non-communicable diseases. These issues will need to be tackled through comprehensive food and nutrition policies and health promotion campaigns.     

Late response and item nonresponse in the Finbalt Health Monitor survey

BACKGROUND: The Finbalt Health Monitor is a collaborative system for monitoring the health-related behaviour, practices and lifestyles in Estonia, Finland, Latvia and Lithuania. This system is based on nationally representative samples and self-administered mailed questionnaires. In comparing the results of national surveys, the awareness of the direction and socioeconomic patterning of the response bias is essential. METHODS: The data were gathered from the cross-sectional surveys conducted in 1998 from Estonia (n = 1362), Finland (n = 3504), Latvia (n = 2322) and Lithuania (n = 1874). An analysis was made of the prevalence of late response, completeness of information obtained from respondents and the magnitude of response bias on the prevalence estimates of health behaviour indicators. RESULTS: The response rates were comparatively high: 68% in Estonia, 70% in Finland, 77% in Latvia and 62% in Lithuania. Late response was weakly related to age, education or place of residence. The total proportion of missing information was below 10% and the sociodemographic patterning for this missing information was similar in all countries. Thus, older and less-educated respondents had more missing information on their questionnaires. Response bias of the prevalence estimates was minimal when it was calculated by using information obtained from late respondents. CONCLUSIONS: The level of nonresponse and missing information was comparable in different countries, not information on health behaviour. Therefore special efforts are needed to design a questionnaire form which appears equally relevant to all respondent groups. The follow-up mailings were an effective way to increase the total response rate, but it was unlikely that they provided an effective way to reach the 'hard core' nonrespondents.     

Primary care workforce development in Europe: An overview of health system responses and stakeholder views

Better primary care has become a key strategy for reforming health systems to respond effectively to increases in non-communicable diseases and changing population needs, yet the primary care workforce has received very little attention. This article aligns primary care policy and workforce development in European countries. The aim is to provide a comparative overview of the governance of workforce innovation and the views of the main stakeholders. Cross-country comparisons and an explorative case study design are applied. We combine material from different European projects to analyse health system responses to changing primary care workforce needs, transformations in the general practitioner workforce and patient views on workforce changes. The results reveal a lack of alignment between primary care reform policies and workforce policies and high variation in the governance of primary care workforce innovation. Transformations in the general practitioner workforce only partly follow changing population needs; countries vary considerably in supporting and achieving the goals of integration and community orientation. Yet patients who have experienced task shifting in their care express overall positive views on new models. In conclusion, synthesising available evidence from different projects contributes new knowledge on policy levers and reveals an urgent need for health system leadership in developing an integrated people-centred primary care workforce.     

Comparison of the incidence of insulin-dependent diabetes mellitus in childhood among five Baltic populations during 1983-1988.

We have carried out a comparison of the incidence of childhood onset insulin-dependent diabetes mellitus (IDDM) between five populations around the Baltic Sea. These were Finland, Estonia, Latvia, Lithuania and Poland. The risk of IDDM is highest in the world in Finland and also very high in Sweden, on the western and northern side of the Baltic Sea. The risk of IDDM in children on the eastern side of the Baltic Sea has not been known before. The data collection period covered the years 1983-1988. A marked variation in incidence was seen within this relatively small geographical area. Among these five populations, the incidence increased with the latitude. Our present results confirmed the very high incidence of IDDM in Finland. The average age-standardized yearly incidence of IDDM/100,000 was in males under 15 years of age 36.9 in Finland, 10.7 in Estonia, 6.4 in Latvia, 6.5 in Lithuania and 6.0 in Poland. In females the incidence was 31.6, 10.0, 6.9, 7.0 and 6.4 in these five populations, respectively. The differential in incidence in Estonia as compared with Latvia, Lithuania and Poland was statistically significant (P = 0.0002). A slight male excess in incidence was found in countries with higher incidence--Finland and Estonia, but in lower incidence countries the sex ratio was opposite (P = 0.019 for the interaction sex-population). During 1983-1988 the incidence increased significantly in Finland but not in other populations although a large year-to-year variation in incidence was observed in each country, particularly in males. We recorded a peak in IDDM incidence in most of these populations around 1986.     

Alcohol consumption in the Baltic Republics

STUDY OBJECTIVES: Premature mortality associated with alcohol intake is of particular concern in several countries of the former Soviet Union. This study explored self reported alcohol consumption (beer, wine, spirits) and its determinants in the Baltic Republics. DESIGN: Cross sectional surveys conducted in 1997. SETTINGS: Estonia, Latvia and Lithuania. PARTICIPANTS: Representative samples of adults age 19-64 (Estonia n=2010; Latvia n=2258; Lithuania n=2139). METHODS: Between country differences in the frequency of alcohol intake were estimated. The odds of consuming alcohol weekly according to socioeconomic characteristics (age, ethnicity, rural/urban area, education, income) were calculated using multiple logistic regression analyses, adjusting for all variables simultaneously. MAIN RESULTS: The proportion of respondents consuming alcohol weekly varied by country (p<0.001) (men: Estonia=61% Latvia=41% Lithuania=55%; women: Estonia=26% Latvia=8% Lithuania=14%). Within each country, this proportion decreased with age in both sexes (p<0. 001), and increased with income in women (p<0.01). In Estonia, the odds of drinking alcohol weekly was significantly lower in respondents of Russian than of Estonian ethnicity (odds ratios (OR) and 95% confidence intervals (95%CI): men=0.51 (0.36, 0.71); women=0. 57 (0.39, 0.81)). In Lithuania, the odds was higher in highly educated men than in those with a low education level (OR=1.48 (1.01, 2.17)). Daily alcohol intake was higher in Estonia than in the other countries, as was the percentage of respondents drinking heavily (equivalent to 80 g/day). CONCLUSIONS: Approximately half the men and one in six women in the Baltic States reported consuming alcohol at least weekly. Age and income were the strongest and most consistent correlates of the likelihood of consuming alcohol weekly. Ethnic differences were observed only in Estonia.     

The sociodemographic patterning of health in Estonia, Latvia, Lithuania and Finland

BACKGROUND: Public health problems in the Baltic countries are typical of Eastern European transition economies. A common assumption is that the economic transition has been particularly difficult for previously disadvantaged groups, and comparative research on the health differences between sociodemographic groups in the Baltic countries is therefore needed. This study compared associations of health with gender, age, education, level of urbanization and marital status in three Baltic countries and Finland. METHODS: The data were gathered from cross-sectional postal surveys conducted in 1994, 1996, 1998 and 2000 on adult populations (aged 20-64 years) in Estonia (n = 5052), Latvia (n = 4290), Lithuania (n = 7945) and Finland (n = 12796). Three self-reported health indicators were used: (i) perceived health, (ii) diagnosed diseases and (iii) symptoms. RESULTS: The prevalence of less-than-good perceived health (average, rather poor or poor) was higher in the Baltic countries (men 66-56%, women 68-64%) than in Finland (men 35%, women 31%). The odds ratios (with 95% confidence intervals) of less-than-good perceived health among the low educated compared to the highly educated in Estonia, Latvia, Lithuania and Finland were 2.03 (1.49-2.77), 2.00 (1.45-2.76), 2.27 (1.78-2.89) and 1.89 (1.61-2.20) among men, and 3.32 (2.43-4.55), 2.77 (2.04-3.77), 2.07 (1.61-2.66) and 1.89 (1.63-2.20) among women, respectively. Diseases and symptoms were also more common among the lower educated men and women in all four countries. However, urbanization and marital status were not consistently related to the health indicators. CONCLUSIONS: The Baltic countries share a similar sociodemographic patterning of health with most European countries, i.e. the lower educated have worse health. The methodological considerations of this study point out, however, that further research is needed to support public health policies aimed at the most vulnerable population groups.     

Lessons learned from the Baltic countries’ response to the first wave of COVID-19

The Baltic countries of Estonia, Latvia, and Lithuania shared a similar response to the first wave of the COVID-19 pandemic. Using the information available on the COVID-19 Health System Response Monitor platform, this article analyzed measures taken to prevent transmission, ensure capacity, provide essential services, finance the health system, and coordinate their governance approaches. All three countries used a highly centralized approach and implemented restrictive measures relatively early, with a state of emergency declared with fewer than 30 reported cases in each country. Due to initially low COVID-19 incidence, the countries built up their capacities for testing, contact tracing, and infrastructure, without a major stress test to the health system throughout the spring and summer of 2020, yet issues with accessing routine health care services had already started manifesting themselves. The countries in the Baltic region entered the pandemic with a precarious starting point, particularly due to smaller operational budgets and health workforce shortages, which may have contributed to their escalated response aiming to prevent transmission during the first wave. Subsequent waves, however, were much more damaging. This article focuses on early responses to the pandemic in the Baltic states highlighting measures taken to prevent virus transmission in the face of major uncertainties.     

Determinants of daily smoking in Estonia, Latvia, Lithuania, and Finland in 1994-2002

AIMS: To investigate time trends in the smoking prevalence and the sociodemographic and psychosocial background of smoking in the Baltic countries in comparison with Finland during 1994-2002. METHODS: Differences in daily smoking according to age, education, urbanization, and psychological distress in the Baltic countries and Finland were studied using postal surveys in 1994, 1996, 1998, 2000, and 2002 among adults (20-64 years old) in Estonia (n = 6,271), Latvia (n = 6,106), Lithuania (n = 9,824), and Finland (n = 15,764). RESULTS: In 1994, 1996, 1998, 2000, and 2002 the prevalence of smoking in Estonia, Latvia, Lithuania, and Finland was 47%, 54%, 46%, and 29% among men, and 21%, 19%, 11%, and 19% among women, respectively. Smoking increased among Lithuanian women from 6% in 1994 to 13% in 2002, but decreased among Estonian men and women. Smoking was generally more common among younger individuals, the less educated, and people with distress in all four countries. The odds ratios for smoking for those with low education compared with those with high education were 2.18 (1.69-2.81), 3.32 (2.55-4.31), 2.20 (1.79-2.70) and 2.80 (2.40-3.27) in men, and 1.90 (1.42-2.52). 3.09 (2.28-4.18), 0.86 (0.59-1.26), and 3.00 (2.53-3.55) in women, in Estonia, Latvia, Lithuania, and Finland, respectively. There were indications of increasing educational differences in Latvian men. Smoking was less common among rural women in all countries except Estonia. CONCLUSIONS: Estonia, Latvia, and Finland show characteristics of the "mature" phase of a smoking epidemic, and smoking may not increase in these countries. In Lithuanian women smoking may increase. Smoking may be increasingly unequally distributed in the future in all the studied countries.     

The sociodemographic patterning of drinking and binge drinking in Estonia,Latvia, Lithuania and Finland, 1994–2002

Background  

Despite the relatively low recorded alcohol consumption level, the Baltic countries (Estonia, Latvia and Lithuania) and neighbouring Finland suffer from similar harmful consequences related to the use of alcoholic beverages, including socio-economic inequalities in alcohol related mortality. Comparative evidence is needed to understand harmful drinking patterns and to implement preventive alcohol policies also in the Baltic countries. This study compared heavy and binge drinking by sex, age, education, urbanisation and marital status in the Baltic countries and Finland.     

Patterns of smoking in the Baltic Republics

BACKGROUND: Tobacco is a leading cause of avoidable death in the Baltic Republics but there is, as yet, relatively little information in the public domain on who is smoking and how this is changing. This information is important for those seeking to develop effective policies to tackle this issue. OBJECTIVE: To determine the pattern of smoking in Estonia, Latvia, and Lithuania. METHODS: Analysis of data on patterns of tobacco consumption from representative surveys of approximately 3000 adults aged under 65 in each country undertaken in 1997. RESULTS: The prevalence of smoking among men is 53.9%, 56.0%, and 53.2% respectively in Estonia, Latvia, and Lithuania. The corresponding figures for women are 24.1%, 10.9%, and 7.6%. For both sexes, current smoking rates are consistently lowest in the age group 50 to 64 and highest in the age group 35 to 49. Education and income are determinants of smoking rates among men but much less so among women. Russian men are more likely to smoke than are men from the majority group in each country. Smoking rates among women are much lower in rural than in urban areas of Latvia and Lithuania but this is not so in Estonia. CONCLUSIONS: Smoking rates among men in the Baltic Republics are already very high. Among women, they still vary considerably. Each country has implemented some measures to reduce smoking. These seem to have been especially effective in Lithuania but, overall, much more action is needed.     

Health-behaviour inequalities among Russian and ethnic majority school-aged children in the Baltic countries

Aims: The main aim of this paper was to investigate whether ethnic heath inequalities exist in self-rated health and risk-taking behaviours (smoking, drunkenness, use of cannabis) between ethnic majority (Estonian, Latvian, Lithuanian) and minority (Russian) population groups of school-aged children in three Baltic countries. Methods: Investigation was carried out in the framework of Health Behaviour in School-aged Children (HBSC) study. Randomly selected students aged 11, 13, and 15 years answered questionnaires in the classroom in 2006. In total, 14,354 questionnaire forms were selected for analysis. Results: Russian boys were more likely (p<0.05) to evaluate their self-rated health positively in schools with Russian teaching language. Odd ratios for current smoking and drunkenness were significantly lower among Russian boys in the schools with Russian language of instruction (p<0.05) in comparison with the reference group. Russian girls did not differ significantly (the exceptions were smoking in Estonia and cannabis use in Latvia) from the majority population girls by self-rated health as well as by the risk of smoking, drunkenness, and use of cannabis. Conclusions: The study found some differences in self-rated health and in risk-taking behaviours between Russian minority and ethnic majority students as well as between students of schools with different language of instruction (majority language vs. Russian) in Estonia, Latvia, and Lithuania. Being a member of minority group was not related with poor self-rated health or involvement in risk-taking behaviours in school-aged children in the Baltic countries.     

Cultural values and population health: a quantitative analysis of variations in cultural values,health behaviours and health outcomes among 42 European countries

Variations in ‘culture’ are often invoked to explain cross-national variations in health, but formal analyses of this relation are scarce. We studied the relation between three sets of cultural values and a wide range of health behaviours and health outcomes in Europe.Cultural values were measured according to Inglehart׳s two, Hofstede׳s six, and Schwartz׳s seven dimensions. Data on individual and collective health behaviours (30 indicators of fertility-related behaviours, adult lifestyles, use of preventive services, prevention policies, health care policies, and environmental policies) and health outcomes (35 indicators of general health and of specific health problems relating to fertility, adult lifestyles, prevention, health care, and violence) in 42 European countries around the year 2010 were extracted from harmonized international data sources. Multivariate regression analysis was used to relate health behaviours to value orientations, controlling for socioeconomic confounders.In univariate analyses, all scales are related to health behaviours and most scales are related to health outcomes, but in multivariate analyses Inglehart׳s ‘self-expression’ (versus ‘survival’) scale has by far the largest number of statistically significant associations. Countries with higher scores on ‘self-expression’ have better outcomes on 16 out of 30 health behaviours and on 19 out of 35 health indicators, and variations on this scale explain up to 26% of the variance in these outcomes in Europe. In mediation analyses the associations between cultural values and health outcomes are partly explained by differences in health behaviours. Variations in cultural values also appear to account for some of the striking variations in health behaviours between neighbouring countries in Europe (Sweden and Denmark, the Netherlands and Belgium, the Czech Republic and Slovakia, and Estonia and Latvia).This study is the first to provide systematic and coherent empirical evidence that differences between European countries in health behaviours and health outcomes may partly be determined by variations in culture. Paradoxically, a shift away from traditional ‘survival’ values seems to promote behaviours that increase longevity in high income countries.     

Occupational exposure to carcinogens in Estonia, Latvia, Lithuania and the Czech Republic in 1997.

OBJECTIVES: The aim of the study was to estimate the numbers of workers exposed to carcinogens in Estonia, Latvia, Lithuania, and the Czech Republic. METHODS: CAREX is an international information system on occupational exposure to 139 known and suspected carcinogens. It provides exposure data and estimates of the numbers of exposed workers by country, carcinogen, and industry. The CAREX method, which has been previously applied in the member states of the European Union, was applied in the present study to the exposure situation in Estonia, Latvia, Lithuania, and the Czech Republic in 1997. The preliminary estimates generated by CAREX were reviewed and revised by national experts mainly for asbestos, benzene, and lead, which were of special interest for this project. RESULTS: The numbers of workers exposed to carcinogens covered by CAREX in 1997 were about 180,000 (29% of employed persons) in Estonia, 260,000 (28% of employed persons) in Latvia, 470,000 (28% of employed persons) in Lithuania, and 1,400,000 (28% of employed persons) in the Czech Republic. The most common exposures were solar radiation (7-13% exposed at least 75% of the worktime), environmental tobacco smoke (4-5% exposed at least 75% of the worktime), wood dust (3-5% exposed), crystalline silica (2-3% exposed), diesel exhaust (2-3% exposed), radon and its decay products (2% exposed), benzene (0.9-1.7% exposed), and lead and inorganic lead compounds (0.8-1.4% exposed). Exposure to asbestos was slightly less prevalent (0.3-1.1% exposed). CONCLUSIONS: These preliminary results indicate that a substantial proportion of the workers in the studied countries were exposed to carcinogens.     

Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002–2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002–2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.     

Hospital reforms in 11 Central and Eastern European countries between 2008 and 2019: a comparative analysis

This paper aims to: (1) provide a brief overview of hospital sector characteristics in 11 Central and Eastern European countries (Bulgaria, Czech Republic, Estonia, Croatia, Latvia, Lithuania, Hungary, Poland, Romania, Slovakia, Slovenia); (2) compare recent (2008 – 2019) hospital reforms in these countries; and (3) identify common trends, success factors and challenges for reforms. Methods applied involved five stages: (1) a theoretical framework of hospital sector reforms was developed; (2) basic quantitative data characterizing hospital sectors were compared; (3) a scoping review was performed to identify an initial list of reforms per country; (4) the list was sent to national researchers who described the top three reforms based on a standardized questionnaire; (5) received questionnaires were analysed and validated with available literature. Results indicate that the scope of conducted reforms is very broad. Yet, reforms related to hospital sector governance and changes in purchasing and payment systems are much more frequent than reforms concerning relations with other providers. Most governance reforms aimed at transforming hospital infrastructure, improving financial management and/or improving quality of care, while purchasing and payment reforms focused on limiting hospital activities and/or on incentivising a shift to ambulatory/day care. Three common challenges included the lack of a comprehensive approach; unclear outcomes; and political influence. Given similar reform areas across countries, there is considerable potential for shared learning.     

Introducing a complex health innovation--primary health care reforms in Estonia (multimethods evaluation)

All post-Soviet countries are trying to reform their primary health care (PHC) systems. The success to date has been uneven. We evaluated PHC reforms in Estonia, using multimethods evaluation: comprising retrospective analysis of routine health service data from Estonian Health Insurance Fund and health-related surveys; documentary analysis of policy reports, laws and regulations; key informant interviews. We analysed changes in organisational structure, regulations, financing and service provision in Estonian PHC system as well as key informant perceptions on factors influencing introduction of reforms. Estonia has successfully implemented and scaled-up multifaceted PHC reforms, including new organisational structures, user choice of family physicians (FPs), new payment methods, specialist training for family medicine, service contracts for FPs, broadened scope of services and evidence-based guidelines. These changes have been institutionalised. PHC effectiveness has been enhanced, as evidenced by improved management of key chronic conditions by FPs in PHC setting and reduced hospital admissions for these conditions. Introduction of PHC reforms - a complex innovation - was enhanced by strong leadership, good co-ordination between policy and operational level, practical approach to implementation emphasizing simplicity of interventions to be easily understood by potential adopters, an encircling strategy to roll-out which avoided direct confrontations with narrow specialists and opposing stakeholders in capital Tallinn, careful change-management strategy to avoid health reforms being politicized too early in the process, and early investment in training to establish a critical mass of health professionals to enable rapid operationalisation of policies. Most importantly, a multifaceted and coordinated approach to reform - with changes in laws; organisational restructuring; modifications to financing and provider payment systems; creation of incentives to enhance service innovations; investment in human resource development - was critical to the reform success.