WHO Barcelona Office for Health Systems Financing, Spain.
Institute of Family Medicine and Public Health, University of Tartu, Estonia.
Health Policy. 2023 Apr;130:104710. doi: 10.1016/j.healthpol.2023.104710. Epub 2023 Jan 22.
Estonia has a legacy of hospital-focused service provision, but since the 1990s, has introduced a series of reforms to strengthen primary health care (PHC). The recent PHC reforms have placed an increasing focus on multidisciplinary care, involving home nurses, midwives, and physiotherapists, and emphasize PHC centres over single physician practices. These incremental reforms, without a supporting legal basis nor explicitly defined timelines and targets, nonetheless demonstrated the ability of financial incentives to drive change. EU structural funds in particular provided essential funding for infrastructure investments in PHC. Yet not all stakeholders supported these initiatives, largely due to the uncertain sustainability of funding. The EHIF also adjusted contract and payment terms to support PHC reforms, with some concessions to PHC providers operating as single practitioners. Despite substantial progress over the last three decades to shift the focus to PHC, there are some important bottlenecks that hinder the progress. These include PHC providers' hesitance to give up their freedom as single practitioners, low interest from specialists to start working at the PHC level, and a lack of financial incentives and adequate funding for a broader scope of PHC services. This looks to become more challenging in the future, as nearly half of family physicians are 60 years old or older. The development of the new PHC strategy in 2023 is very timely to comprehensively address these bottlenecks and to set the vision for the future of PHC in Estonia.
爱沙尼亚在以医院为中心的服务提供方面有着悠久的历史，但自 20 世纪 90 年代以来，已经引入了一系列改革来加强初级卫生保健（PHC）。最近的 PHC 改革越来越注重多学科护理，涉及家庭护士、助产士和物理治疗师，并强调以 PHC 中心代替单一医生执业。这些渐进式改革没有支持性的法律基础，也没有明确规定时间表和目标，但仍然展示了财务激励措施推动变革的能力。欧盟结构基金尤其为爱沙尼亚 PHC 的基础设施投资提供了必要的资金。然而，并非所有利益相关者都支持这些倡议，主要是因为资金的不确定性。EHIF 还调整了合同和支付条款，以支持 PHC 改革，对作为单一从业者运营的 PHC 提供者做出了一些让步。尽管在过去三十年中为将重点转移到 PHC 方面取得了重大进展，但仍存在一些重要的瓶颈，阻碍了进展。这些瓶颈包括 PHC 提供者不愿放弃作为单一从业者的自由、专家对在 PHC 层面工作的兴趣较低，以及缺乏财务激励和足够的资金来扩大 PHC 服务范围。随着近一半的家庭医生年龄在 60 岁或以上，未来这将变得更加具有挑战性。2023 年新的 PHC 战略的制定非常及时，可以全面解决这些瓶颈，并为爱沙尼亚的 PHC 未来设定愿景。
