Elsevier

Health Policy

Volume 82, Issue 1, June 2007, Pages 51-61
Health Policy

Satisfaction with the access to the health services of the people with chronic conditions in Estonia

https://doi.org/10.1016/j.healthpol.2006.08.004Get rights and content

Abstract

After the implementation of the primary health care reform in Estonia, most of chronic conditions are managed by family doctors (FD) in collaboration with specialists. Although the general population has demonstrated the increase in satisfaction with health care after the reform, it has been questioned if people with chronic diseases have been left on a more disadvantaged position in the new system with some restrictions in the access to specialists.

Objective

To investigate the satisfaction of people with chronic conditions with the access to the health services and compare them to those who did not have a chronic illness.

Method

In November 2005, a random sample of Estonian residents aged 15–74 were personally interviewed using structured questionnaires (n = 1446), 29% of them reported to have a chronic illness.

Results

The people with chronic conditions were less satisfied with the access to the health services. They were more satisfied with their family doctors, but less with the health insurance system and they often reported their problems in seeing the specialist. Compared to other respondents, the people with chronic conditions visited their FDs and specialists more often, but no significant differences were found between their waiting times to see the FD or a specialist.

Conclusion

In Estonia, the people with chronic conditions do not have organisational barriers in their access to the health services. As frequent users of health services, they perceive the shortages of the health system more obviously than the rest of the population and it may reflect their satisfaction with the different aspects of the health system as well as the access to the health services.

Introduction

The main goal of every health system is to improve the population's health. When individuals interact with the health system, it influences their well being through improvements in health. People's well being and satisfaction with the health system are also related to the way they are treated, how easily they get the health services needed, and the environment where they are treated [1]. One particular group of the population who needs and uses many and various health services are people with disabilities and chronic conditions and the elderly [2], [3], [4]. Chronic conditions are increasingly the primary concern of health care systems throughout the world [5]. Chronic conditions are the leading reasons why people seek medical care, yet the current health care systems may not address the needs of those people [3], [6], [7], [8]. It has been argued that health care systems are mostly designed for acute care, and patients with acute symptoms and concerns may crowd out the less urgent needs of chronic patients [9]. Also, in several studies people with chronic conditions have been found to be less satisfied with the quality as well as the access to health services [3], [10], [11], [12]. The reasons for dissatisfaction might be limited access to health services, dissatisfaction with the costs of care, or also the fragmentation of care, the lack of continuity and the coordination of care for chronically ill people [10], [12], [13], [14], [15].

In different health systems the solutions how patients with chronic diseases are handled may be different. Before the 1990s, the Estonian health care system was rather specialist-oriented, and people with chronic diseases were mostly treated by specialists. Within the reorganised primary health care (PHC) system since the early 1990s PHC doctors have taken over a number of responsibilities which earlier belonged to the area of specialised outpatient care, including management of the care of chronically ill people. The implementation of gate-keeping functions of PHC doctors, as well as the patient list system, also changed the principles of care of chronic patients. The role of specialists in the management of chronic patients is mostly defined as a consultant, and most patients who need to see specialists need referrals from their family doctors (FD). A referral from a FD is not obligatory if the specialised medical care is provided in connection with an injury, tuberculosis, eye disease, dermatological or venereal disease or in the case when gynaecological or psychiatric care is provided [16]. To guarantee access to the health services, the Estonian Health Insurance Fund (EHIF) has established the standards for waiting time for the FD, as well as for outpatient specialised care. According to the contracts concluded between the providers of health services and the EHIF, FDs should be available in one working day for patients with acute diseases and in three working days for patients with chronic diseases. The scheduled appointment time for specialised outpatient care should be no longer than 4 weeks.

As demonstrated in previous studies, the Estonian people have accepted the new PHC system, and during the first years after the formal implementation of the PHC reform, satisfaction rate with family doctors has increased [17], [18], [19]. Access to PHC services is good, for elderly and people of the lower social class as well [4]. Improved management of some chronic conditions by family doctors has been found [20]. However, the results of another study demonstrated that large differences in the use of health services were observed in relation to socio-economic status, with a more favourable socio-economic status being associated with a higher probability of using health care services which may indicate the possibility of limited access [21].

Assurance of the availability of high-quality health services to all the persons in need of them is one of the objectives of the health policy in Estonia [22]. As it is known from previous studies, access to the health services in Estonia has been rather good in general and people have been satisfied with the services provided [4], [17]. At present, it is not known whether people with chronic conditions have the same access to the health services as others, or if they are in a more disadvantaged position in their access to health services as reported by researchers from other countries [3], [6], [7], [8], [9], [10], [11], [12]. Thus, in this study we investigated satisfaction of people with chronic conditions with access to health services and compared them to those who did not have a chronic illness. The results of this study might support the implementation of the national health policy as well as the further development of the primary health care system to improve the continuity and coordination of care.

Section snippets

Methods

In November 2005, a random sample of Estonian residents aged 15–74 were personally interviewed using structured questionnaires (n = 1446). The sample of the study was formed by self-assessment: a proportional model of the total population aged 15–74 was used, where all the respondents represented equally sized groups. A two-staged stratification was made in order to form the sample. First, the population was divided into six strata on the basis of their localisation, while the size of the sample

Sample description

Out of 1446 respondents, 419 or 29% reported having a chronic illness which had restricted their everyday life activities. Some differences existed in demographic characteristics and the health status between the respondents who had a chronic illness and those who did not (Table 2). The people who reported having a chronic illness were likelier to be women (p < 0.05), older persons (p < 0.0001), less educated (p < 0.05) and persons with lower income (p < 0.0001). Of those people who reported having a

Discussion

Chronic diseases are a major cause of death and disability worldwide. According to the WHO non-communicable diseases now account for 46% of the global burden of disease [23]. The results of the present study demonstrated that almost one-third of the Estonian adult population suffers from chronic conditions which have in some way restricted their daily activities. As expected, people with chronic conditions also reported poor health status more often compared to other respondents. Comparing to

Acknowledgements

This study design and data collection were financed by the Ministry of Social Affairs of Estonia and the Estonian Health Insurance Fund. Data analysis was performed by independent researchers from the University of Tartu.

References (28)

  • L. Gask

    Role of specialists in common chronic diseases

    British Medical Journal

    (2005)
  • M.W. Battersby

    Health reform through coordinated care: SA HealthPlus

    British Medical Journal

    (2005)
  • T. Bodenheimer et al.

    Improving primary care for patients with chronic illness

    Journal of the American Medical Association

    (2002)
  • L.I. Iezzoni et al.

    Satisfaction with quality and access to health care among people with disabling conditions

    International Journal for Quality in Health Care

    (2002)
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