EMS Around the World: COVID Prompts Estonia to Invest

The Estonian EMS system comprises 102 operational brigades deployed to 60 stations. To boost the services’ availability to the inhabitants of some 2,222 islands and islets along the country’s Baltic coast, the nation’s authorities are planning to invest in medical helicopter services. 

“Estonia is planning to enhance its air ambulance capabilities by creating two bases for medical helicopter operations,” says Indrek Soosaar, an adviser to the Health System Development Department of the Estonian Ministry of Social Affairs.

Estonia, a country with a population of about 1.33 million, maintains a fleet of three AgustaWestland AW139 helicopters that are operated by the Police and Border Guard Aviation Group. The helos are primarily used for search-and-rescue missions but are also involved in medical transport and border control activities. 

New Priorities

Prior to the coronavirus pandemic, Estonian authorities did not consider the establishment of a dedicated helicopter EMS unit as a priority. However, with the European Union (E.U.) rolling out its Recovery and Resilience Facility (RRF), a program to provide its 27 member states with more than U.S. $821 billion in loans and grants to rebuild their economies post-pandemic, Estonia included the creation of such a service on its list of E.U.-funded projects.

The “acquisition of at least two multifunctional…medical helicopters, along with infrastructure” was valued at some U.S. $52.5 million, according to official government documents.

Estonian emergency medical services are provided to the country’s inhabitants free of charge, with the expenses paid by the state-run Estonian Health Insurance Fund, and overseen by the Estonian Health Board. Ambulances can be either state-owned or owned by private operators, Soosaar says.

“The majority of brigades have three members and are led by nurses, but there are also brigades led by physicians,” she says. “There are at least 102 operational brigades, most of which are nurse-led. There are also physician-led ambulances. They mostly have three members each, but there also are two-member support brigades, as well as mobile intensive care units. Additional brigades are deployed to rectify the system’s increased needs due to the coronavirus pandemic when necessary.” 

In spite of the country’s relatively small area of some 17,462 square miles, Estonia is the E.U.’s third most sparsely populated member, with a density of only about 30.3 persons per square kilometer, according to the Estonian government’s official website. This is almost barely a quarter of the E.U.’s average of 116.7. Due to this, when designing the country’s EMS system, the authorities must seek to deploy the nation’s assets in a way that maximizes their efficiency. 

Island Care

There are 60 EMS stations located across the country, combined with smaller posts manned by local first responders on select islands. The country’s largest island, Saaremaa, has a population of more than 31,000 persons, but many islands have populations of just a few persons each, and countless are uninhabited.

These first respondents “receive medical supervision and support via telemedicine services,” according to the ministry advisor. 

In addition to the forthcoming investments in helicopter services, other projects in the pipeline for the Estonian EMS system include developing the country’s electronic patient record and information systems, Soosaar says.

In 2002 Estonia’s authorities moved to decentralize the country’s healthcare system by passing the Health Services Organization Act, which introduced four types of healthcare: primary care, provided by family doctors; emergency medical care; specialized (secondary and tertiary) care; and nursing care.

“Healthcare providers are autonomous entities operating under private law. Most hospitals are either limited liability companies (for-profit) owned by local governments or foundations (not-for-profit) established by the state, municipalities, or other public agencies. Most ambulatory providers are privately owned,” according to a report by WHO’s European Observatory on Health Systems and Policies.

Estonia prides itself on being the first country in the world to allow its citizens to vote online in the local elections it held in 2005, and the state functions as a digital service. Its authorities say the country’s approach is to offer a wide range of state services to people outside of Estonia, such as registering companies online.

In line with this approach, Estonia was one of the first E.U. member states to join the bloc’s digital COVID-19 certificate initiative. Since last July it has been possible for Estonians to create digital immunization, coronavirus recovery, and negative test certificates with the use of a state-run patient portal. 

Growing Budgets

As in numerous other countries, the pandemic has triggered a hike in Estonian spending on healthcare. In April 2020, as Estonia and many other E.U. member states were going through their first lockdowns, the country’s government approved the allocation of additional U.S. $242 million, or about $181.50 per inhabitant, to cover extraordinary healthcare costs.

The largest share of these costs, about $170 million, was used to ensure additional funding for hospitals and specialist care, increasing the intensive care capacity of local hospitals.

“To ensure quality medical care, hospitals purchase additional equipment, including ventilators, and in some cases construction work is required to install partitions or rebuild hospital entrances,” the Ministry of Social Affairs said in a statement.

Estonia’s ambulance fleet was allocated some $5.8 million to expand its capacities, according to the statement.

Asked about COVID’s impact on the functioning of Estonia’s emergency services, Soosaar says the pandemic has emphasized the importance of recruiting additional employees amid staff shortages. 

“All in all, the EMS system has held up well,” she says. “Additional brigades have been set up to help with testing potential corona patients and to enhance availability while the decontamination of ambulances has taken up more time than usual.

“EMS personnel have helped to manage outbreaks at nursing homes…[but] the shortage of staff has been a major problem and forced the personnel to do more overtime work.”

Jaroslaw Adamowski is a freelance writer based in Warsaw, Poland.