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Attempts to integrate long-term care

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
(14) 2009
Gerli Paat, Ain Aaviksoo
Health Policy Issues: 
Long term care
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no


The development and funding of nursing care in Estonia has been very poor so far and did not get much attention even in times of fast economic growth. However, at the end of April 2009, the regulation ?Nursing and long term care infrastructure development measure? of the Ministry of Social Affairs (MoSA) was passed as set by ?2007-2013 Structural Assistance Act?. Its goal is to ensure better access to nursing and long term care services. Capital investment into LTC hospitals.

Purpose of health policy or idea

Long term care (LTC) in Estonia has been paid relatively little attention compared to other health care services. In April 2009, MoSA prepared the regulation "Nursing and long term care infrastructure development measure" which aims at ensuring better quality and availability of nursing care. The general goal is to improve inpatient and outpatient care services, purposeful usage of health insurance funds, and to offer more diverse long term care services that meet population needs. The measure is financed by the European Regional Development Fund (ERDF).

The measure aims at increasing capital investments into long term care hospitals because: 

  1. State support has so far been relatively small and 
  2. several municipalities have undertaken their own steps to improve the situation (e.g. Tallinn Municipality) 

In addition Tallinn's City Government decided in 2008 to participate in a project "called Future Care - Integrated Model of Care for the Aging Europe" as a regular partner to INTERREG IVC (ERDF). The project is expected to last until 2011. By now, the document "Integrated long-term care in Estonia: Providing health care, nursing care and social care services" has been prepared.

On an individual level the aims of the organization of care services and the integrated care system described in the current document are

  • achieving the best possible quality of life for people with care needs,
  • basing the assessments on everyone's individual needs and
  • securing coping in one's habitual environment (home) for as long as possible.

With the services provided to the elderly, the elderly with health and coping difficulties should also have a chance to continue a decent life and actively participate in public, social and cultural life.

The macroeconomic goals of integrated care are

  • increased efficiency of care,
  • expedient use of expensive care services (institutional care) and
  • development of community-based care services.

Main points

Main objectives

  • Better availability and quality of nursing and long term care
  • Achieving the best possible quality of life for elderly population
  • Create opportunities for elderly population to continue an active way of living
  • Integration of long term care and improvements in its efficiency

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-dependent system-neutral

Political and economic background

In 2001, the Ministry of Social Affairs prepared the Nursing Care Master Plan 2015 in order to provide nursing care targets to match the hospital targets set out in the Hospital Master Plan 2015. The main changes recommended by the Hospital Master Plan 2015 were to turn small hospitals (mainly owned by local governments) into nursing care homes and to develop non-institutional nursing care services that provide home nursing and day-care nursing.

Reforms in the healthcare system are closely linked to the social welfare system. The systems of health care and social welfare are relatively separate from each other, which causes problems in terms of the transfer of people between the different systems. The accessibility and quality of long-term care services is limited, due to the fact that the welfare and healthcare systems are financed from different sources - from the state budget and through the Estonian Health Insurance Fund (EHIF), respectively. Many social care home residents also need long-term care, but the amount of care provided is constrained by limited resources of municipal budgets. As the target group of long-term care and welfare services is largely overlapping, integration and better coordination of services are required to respond more effectively to the varying needs of elderly and chronically ill people.

Strategies to optimize integrated care in Estonia are developed by interdisciplinary working groups, but at the time of writing have not yet been implemented. For successful implementation, consensus between the different care sectors is required, along with legislative support from state bodies. Changes are also needed in financing: both combined financing from the EHIF, municipalities and personal resources; and at the service organization level, in terms of descriptions of minimum requirements and quality requirements for all long-term and social care. A 2007 amendment of the Health Services Organization Act (entering into force in 2008) provides an opportunity to arrange long-term service provision by the family doctor. This should bring home nursing care service closer to the patient, as discussed earlier.

Long-term care is usually provided to elderly people with several chronic illnesses, who require help with treatment procedures and who cannot cope with the tasks of everyday life; and to adults with multiple conditions and partial incapacity to cope with everyday life, such as geriatric patients. This type of care is often of insufficient quality and does not meet contemporary requirements and expectations due to inadequacy of premises, lack of trained personnel (nurses, caregivers) and lack of appropriate financing for the services. Many LTC hospitals and welfare institutions are faced with an acute shortage of space and the standards are relatively low. In addition, there is still a shortage of long term care beds. In terms of future challenges, appropriate facilities are needed to support the development of new service delivery models. Financial support worth €27.5 million from the ERDF for the period 2007-2013 should facilitate the development of long term care facilities and improve the quality of services.

The purpose of financial support is to improve nursing and long term care, also the quality and availability. The support is mainly directed to construction and reconstruction projects. The funding may be requested by inpatient nursing and LTC licence holders and 35 licence holders opted to request the financial support.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no

Origins of health policy idea

As a result of the fragmented, arbitrarily integrated social welfare system, the consistency and diversity of care to the target audience is inadequate. In a situation where nursing care and LTC is poorely available to the population and the length of stay in nursing hospitals is limited, the care services provided do not meet the actual need for them. Yet another problem is that often it is unclear who is responsible for the person in need of long term care and who coordinates the provision of all care services. Care services are provided inadequately and with uneven availability also because of the lack of resources, as all the responsibilities of arranging care provision are assumed by local government. Moreover, the principles of care financing differ - nursing care is financed by EHIF, the cost sharing in long term care differs but as average 50,3% is covered by person or family. Given that the price for a place at LTC institution varied from 260-1100EUR in 2008 (average salary in Estonia for 2008 was 825EUR), it also makes care unaffordable for some groups of the population. The total capital investment demand of long-term care, estimated according to the Hospital Master Plan, is 630 million EEK (more than 40 million EUR).

A possible reason for uneven quality of social welfare services is also the regional coverage of LTC nursing care. Personnel availability is varying across different regions and care provision institutions. Yet another problem is that there are no uniform quality standards for services and no specific estimates for the actual need for care services.


Initiators of idea/main actors

  • Government
  • Payers

Approach of idea

The approach of the idea is described as:

Stakeholder positions

Ministry of Social Affairs (MoSA) - formed a committee with the task of deciding upon the distribution of financial resources from European Structural funds targeted to nursing and long term care.

LTC institutions - decide upon using the funds (i.e. the development of nursing care, etc.).

EHIF - finances partially LTC and nursing services, yet their role in the development of nursing care and LTC has been relatively poor.

Local governments - are responsible for ensuring the population with nursing care and LTC in their communities.

Actors and positions

Description of actors and their positions
Ministry of Social Affairsvery supportivevery supportive strongly opposed
Local Governmentvery supportivevery supportive strongly opposed
EHIFvery supportivesupportive strongly opposed

Influences in policy making and legislation

The regulation of MoSA lies down the activities supported by the structural funds. The support may be requested by all social welfare institutions that have been granted a nursing and LTC licence.

Government regulation approves the final list of LTC hospitals that receive support from EROF.

Legislative outcome


Actors and influence

Description of actors and their influence

Ministry of Social Affairsvery strongstrong none
Local Governmentvery strongneutral none
EHIFvery strongstrong none
Local GovernmentMinistry of Social AffairsEHIF

Positions and Influences at a glance

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

Adoption and implementation

For implementation of the principles of nursing care and LTC and ensuring the sustainability of the volume of services, the planning of investments is expected to take into account the need of care services and the locations of infrastructure in a county. If possible different social welfare and health services should be provided from one location, taking into account the service requirements and economic feasibility. Priority is given to those county centres where the provision of services is the poorest. Each county has developed a plan for LTC and social care provision. In addition, MoSA has commissioned a study to develop a sustainable financial model. The results are to be published by the end 2009.

Tallinn City Government has come to light with the proposal that at the current development level the most appropriate model of integrated care for Estonia is the model of a co-coordinating network. The co-coordinating model implies that the people and institutions in the network have focused their activities clearly on cooperation. The family physician is the key person in referring patients to nursing care services and in referring a local government's social worker to welfare services. The central position is taken by the case manager, i.e. the care co-coordinator, whose aim it is to guarantee people in need a package of services that would be as suitable and economic as possible. Given the practices already implemented in Estonia, it is best to start with case management at the level of county governments (also in bigger towns), who have the responsibility to organize and monitor primary health care.

The integrated system of nursing and LTC in Estonia is best described by the following figure.

Long term care integration in Estonia

Monitoring and evaluation



Expected outcome

The measure is expected to have a positive impact on hospital infrastructure and on the optimization of the organization of work which would allow more efficient use of limited resources.

The expected positive effect on integrated LTC and nursing care services arises from better planned and organised services targeted to individuals with combined health issues and/or population groups with similar needs and health problems.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high

Although additional funding was given to the development of healthcare services, it is still a long way to go till the integrated healthcare services will start functioning according to the expectations. This would require close cooperation between many different parties and stakeholders and a common understanding about the organization of an integrated LTC scheme. Although Tallinn City Government has now proposed an integrated nursing and LTC scheme, it is essential that all such parties involved are ready to implement it. Moreover, it is also important that the development of integrated care is supported by the State and EHIF.

Recently, co-payments were increased in Estonia. The system is underfunded and non-investments will increase amortisation cost. Without full implementation of a sustainable financing model, the impact will be modest. 


Sources of Information

  1. Estonian Hospital Master Plan. 2002.
  2. Koppel A, Kahur K, Habicht T, Saar P, Habicht J, Ginnenken E. Estonia Health system review. Health Systems in Transition 2008.
  3. The Act of Organization of Health Services (Tervishoiuteenuste korraldamise seadus)
  4. Ministry of Social Affairs (Sotsiaalministeerium);
  5. The Long Term Care System Strategy of Estonia for 2004-2015 (Eesti hooldusravivõrgu arengukava 2004-2015).
  6. Eesti hooldus- ja hooldusravisüsteemi võimalikud finantseerimismudelid.Seminar 28.05.2009 materjal. Olavi Grünvald. Price Waterhouse Coopers (PwC) 2009
  7. Integrated Long-term Care in Estonia: Providing health care, nursing care and social care services. 

Author/s and/or contributors to this survey

Gerli Paat, Ain Aaviksoo

Suggested citation for this online article

Paat, Gerli, and Ain Aaviksoo. "Attempts to integrate long-term care". Health Policy Monitor, October 2009. Available at