Background information about dementia and home care services
Estonia gained independence in 1918 and again in 1991 after over 40 years’ occupation by the Union of Soviet Socialist Republics (USSR). From 1991 to 2000, new principles of social security were formed and new insurance systems were established. In Estonia, there is a high percentage of elderly people, particularly elderly single women living alone.
Since the early 1990s, the Estonian health care system has seen a number of reforms, mainly involving the reorganisation of the public funding system and a reduction in the number of hospitals and beds, whilst at the same time trying to make a more efficient use of funds. Consequently, the Estonian healthcare system has changed from a centralized state-controlled system to a decentralised one and from a state-funded system to one funded mainly through health insurance contributions. However, the health system had difficulty coping with the extent of decentralisation and consequently in the late 1990s, the Ministry of Social Affairs had to re-establish responsibility for overall health care planning (Hit Summary, 2004). Attempts have also been made to improve the quality and accessibility of general medical care services and to reintroduce the system of general practitioners.
The ongoing Estonian healthcare reform plans to reorganise health care so as to create a three levelled system with 4 centres for intensive care, a low concentration of long-term care (mainly in county centres) and dispersed primary health care (general practitioners). It is planned to limit the length of stays in hospitals. Consequently, there is a need to develop home nursing services and home care. There is a need to better coordinate health care and social welfare, particularly between general practitioners and home care and between long-term care, home nursing and home care (Kõre, 2005).
Legislation relating to the provision of home care services
The Social Welfare Act of 1995 (consolidated text December 2003) covers the provision of domestic services which are defined as being services provided to persons in their homes which help them cope in familiar surroundings. The Act states that local government authorities shall establish a list of domestic services and the conditions and procedure for their provision.
§27 deals with the social welfare of the elderly. It states, “ In order to assist the elderly to cope in surroundings familiar to them and to have a life of equal value with other persons, rural municipality governments and city governments and city governments shall:
- Establish opportunities for cheaper alimentation;
- Ensure the accessibility of information concerning services provided and establish opportunities for the use of social services;
- Establish opportunities for interaction and hobbies;
- Ensure the security and independence of the elderly living in social welfare institutions, respect for their private life and the opportunity to participate in decision-making pertaining to their physical and social environment and future.”
In the “Development plan of Estonia’s nursing care network from 2004 to 2015”, it is stated that by 2007, adjustments in legislation based on the conception of nursing care (as well as welfare services) should enter into force.
Organisation and financing of home care services
The systems for health care and social welfare are relatively separate. Funding for social welfare comes from local government budgets, the state budget, people who voluntarily engage in social welfare and various other sources. The state budget provides local governments with funds for social welfare but the local governments may also have to use their own budgets for this purpose. Voluntary organisations, churches, foundations, commercial associations and non-profit organisations can all provide social services.
Local administrations are responsible for providing welfare services but this obligation is stated in the Law on Social Welfare of 1995 in very vague terms so the actual provision of services varies from one local administration to the next. The local administrations can provide services themselves or purchase them from private or public organisations. There are over 200 municipalities in Estonia and many of them are very small. For this reason, it is impossible for them all to offer a full range of services. Nevertheless, some of them join together and offer services jointly.
People who are in need of services must contact their local government in order to organise for a social worker to assess their needs and determine the kind of care they will receive (based on their needs and financial situation). Elderly people may be offered a geriatric assessment. Geriatric assessments were introduced in 2004. They consist of a single assessment to determine clients’ needs and to provide them with suitable services covering health care, nursing care and welfare services. The geriatric assessment team is composed of a physician, a nurse and a social worker and an international standardised tool is used for the assessment.
The providers of social services may charge beneficiaries or their families for their services. Children and kinsfolk are legally obliged to take care of their elderly relatives. However, if they are unable to do so or if an elderly person does not have any relatives, the Government must assume responsibility for their care.
In 2001 the Estonian Health Insurance Fund (EHIF) was created and replaced the existing Central Sickness Fund. It covers 94% of the population and is responsible for contracting health care providers, paying for health services and refunding medication costs amongst other things. In 2003, the EHIF started to cover expenses for long-term care, nursing care and some home care (Hit Summary, 2004).
Kinds of home care services available
In the Law on Social Welfare, domestic services are defined as services provided to persons in their homes which help them cope in familiar surroundings and it is stated that a list of domestic services and the conditions and procedure for their provision shall be established by local government authorities.
Social care may take the form of cash benefits (including daily allowances for daily living or personal assistance) or benefits in kind. However, services for people in need of assistance are mainly provided in special social care homes.
Services that are specifically provided for people with mental health problems or disabilities are the responsibility of the state. As such, they are managed and financed by the Ministry of Social Affairs and the state budget (Hit summary, 2004).
The Health and Long-term Care in Estonia: National report (Social Welfare Ministry, describes care services as:
- Care by relatives/informal care – care or basic nursing care of an elderly or disabled family member or a relative in home conditions. Local governments offer supporting services to help people taking care of their relatives, e.g. domestic help and interval care, and assistance for establishment and activities of various support groups;
- Family care – care of a person in a suitable family where he/she is not a member of family. Local governments offer supporting services to help the carers and pay a compensation to cover the costs related to caring, which is not a remuneration for work;
- Home services (domestic help) – services offered to people at home, helping them cope in their usual environment, excluding the care that requires physical contact. Long-term supportive service, required continuously for independently living people to enable them to use general public services. Home services comprise, for example, cleaning and care of the housing, procurement of food, pharmaceuticals, other necessities and firewood or other fuel, information and assistance in administrative matters etc.;
- Accommodation or housing service (including adaptation) – supplying a room for around-the-clock accommodation, including rental of accommodation. Adaptation of accommodation for the person to improve the possibility to move in the room and cope independently. In institutional welfare, providing of security must be offered in addition;
- Personal assistance service – helping people with low coping capacity to perform activities, helping them to move around, in issues of personal hygiene, administrative matters at home and outside. Help is provided also in procedures requiring physical contact with the person. The main purpose of the service is to activate the person or maintain his/her capacity to cope;
- Day-care in a welfare institution – supporting a person's or his/her family's coping capacity in institutions where the person spends the day. Day-care is provided by day centres where social services, developmental and hobby activities are offered during the day. An elderly or disabled person can visit the day centre as often as he/she wishes (has need for). Specialisation on the day care of the demented is possible. The purpose of day centres is to maintain the welfare and activity of their clients;
- Long-term care in institution;
- Strengthened support care service – improving the capacity of a person to cope independently and/or maintain the quality of life of a person with strong multiple disability by means of treatment, rehabilitation and assistance in everyday life;
- Strengthened supervision care service – maintaining the quality of life of a person with increased level of danger by means of assistance in daily life procedures, in a care unit with enhanced supervision and assistance.
Consultation with people with dementia and carers
In the second half of the 1990s, with the help of a Dutch health care quality organisation, satisfaction surveys of patients and employees were launched. It is unclear whether people with dementia took part in these surveys.
According to §32 of the Social Welfare Act of 1995, in the provision of social services, social benefits and other assistance, a person’s wishes shall be considered except in the cases provided for in §§19, 20 and 25 of the said Act. These paragraphs cover people “of unsound mind” who have been placed in social welfare institutions without their consent and presumably do not cover people with dementia still able to live in their own homes.
- European Observatory on Health Systems and Policies, Health Care Systems in Transition, HiT Summary for Estonia, WHO Regional Office for Europe, http://www.who.dk/document/e85516sum.pdf#search='HiT%20summary%20AND%20Estonia'
- Kõre, J. (2005), Possibilities for integration of health and welfare services in Estonia in liberal political and economical circumstances, http://www.socialeurope.com/pdfs/Venice/presentations/kore.pdf #
- Merle Malvet, Pille Liimal and Kaja Vaabel (2005), Social care and welfare for the elderly and social services, http://www.parnu.ee/raulpage/welfa97.html#elderly
- Valdja, U. (2005), WHHO-Compendium Text (extract on the Estonia), http://www.nahc.org/WHHO/WHHOcomptext.html
- Social Welfare Act of 1995, http://www.legaltext.ee/text/en/X1043K6.htm
- Social Welfare Ministry (2005), Health and Long-term Care in Estonia: National report, April 2005, unpublished report.
- Social Welfare Ministry (2005), Developmental plan of Estonia’s nursing care network from 2004 to 2015, (http://www.sm.ee for Estonian version).
Last Updated: mercredi 15 juillet 2009