Upon the creation of health insurance funds, mostly 1 % of wages was set as membership dues, yet it became apparent quite soon that this was not enough to cover all expenses. Thus the insurance fee was soon increased to 2–3 % of the worker’s wages. The employer had to add an equal amount or at least 2/3 of the fees collected from the workers. Workers were paid illness benefits of 1/2 to 2/3 of the worker’s daily wages according to the amounts approved by law and the means available to the health insurance fund. In cases of accident, 2/3 of the daily wage was paid out. In the case of childbirth, support amounting to 50– 100 % of the monthly wages was paid out. The funeral benefit in the event of death was 30 days wages. The family members of workers were also insured and they had the right to receive benefits amounting to 50 % of the benefits of workers.
The newly established health insurance funds did not have a chance to gain experience in managing their affairs before the First World War began, followed by revolution. Many workers were mobilised for military service, working time was reduced in factories, many large enterprises went broke, currency values plunged, food was in short supply, and diseases and epidemics tallied up large numbers of victims. All this decreased the income of health insurance funds and increased their expenditures. Since the possibilities for increasing insurance fees were limited, the extent of the insurance (insurance restrictions were established for family members) or the size of benefits was decreased instead. In spite of everything, revolution had a favourable effect on the development of health insurance funds. Insurance legislation was extended to all branches of industry, whereas handicrafts and construction enterprises with at least five employees also had a right to insurance. Enterprises were required to transfer medical institutions to health insurance funds.
Health insurance funds went through their most difficult period during the German occupation in 1917–1918. Industrial production declined, many industrialists neglected to pay insurance fees, and health insurance fund reserves declined. The owners of Tallinn’s publishing houses of that time were in the front ranks of those who refused to pay.
A meeting of 17 health insurance funds took place in Tallinn on 16 April 1917 to organise their work. A central bureau of health insurance funds was elected at this meeting. Its task was to work out a plan for the unification of health insurance funds together with a joint statute. This statute was approved on 13 November 1917. This joint health insurance fund comprised the health insurance funds of 16 enterprises by the beginning of the following year, covering a total of 2456 workers with 3724 family members.
Tallinn Municipal Enterprises Health Insurance Fund Board of Directors and office workers in 1926.
Tallinn Municipal Enterprises Health Insurance Fund Board of Directors, Auditing Committee and employees in 1932.
A new and successful period in the work of the health insurance fund began during the era of the Republic of Estonia. The sickness insurance legislation passed by the Russian Provisional Government on 25 July 1917 remained in effect in the Republic of Estonia since other legislation had not been passed. Changes were made to that sickness insurance legislation in 1923, 1934 and 1936. The Republic of Estonia did not manage to pass its own sickness insurance legislation due to major conflicts, although several attempts were made to that end. One of the most serious conflicts was the right to found health insurance funds and the organisation of the management of those funds.
The economy was on the upswing in the early 1920’s and opportunities for compensating for medical care and disability expanded. Since some smaller health insurance funds had encountered serious difficulties over the course of several years of operation and several health insurance funds merged, the idea emerged to start coordinating the work of health insurance funds more effectively. The Tartu Health Insurance Fund mentioned the need for an association for the first time in 1922. The Estonian Association of Health Insurance Funds was created in 1923 after a long period of preparation. The greater portion of smaller health insurance funds operating in Estonia belonged to this association at different periods. Membership in the association was voluntary. About 3/4 of the health insurance funds were part of the association in the 1930’s. The main role of the association lay in disseminating information among its members and in participating in debates concerning the organisation of sickness insurance and medical care. Publication of Haigekassa (Health Insurance Fund), the voice of the association, began in 1925. The paper shortly changed its name and was published until 1940 under the name Töö ja Terwis (Work and Health).
Representatives of workers managed and founded Estonian health insurance funds until 1929. Regardless of their great political influence, industrialists did not succeed in convincing workers to include the owners or managers of enterprises in the administration of health insurance funds. In this respect, the Republic of Estonia differed initially from other European countries, where the owners of enterprises founded and administered health insurance funds either partially or completely. The managers or owners of enterprises nevertheless also gained their say in the administration of health insurance funds in 1929.
Tartu General Health Insurance Fund activity report in 1939.
Estonia was conspicuous in Europe with its relatively low proportion of sickness insurance – only 17.9 % of the population was covered. Sickness insurance essentially remained the privilege of industrial workers and recipients of the Vabadusrist (Cross of Liberty). Persons who worked in agriculture, education, or some other sector and the members of their families had to pay for health services themselves. It was not until the latter half of the 1930’s that several acts of legislation went into effect that extended sickness insurance to civil servants and governmental employees, university teachers and professional military personnel together with the members of their families.
Major outbreaks of disease significantly affected the work of health insurance funds. The years 1933–1934 were difficult for Tallinn’s Health Insurance Fund because that is when Tallinn suffered a serious outbreak of influenza. Tallinn nevertheless managed to recover from the crisis in a few years: most likely due to increasing insurance fees, which were increased to 6 % of each member’s income.
The work of health insurance funds towards the end of the 1930’s was nevertheless not equally successful. Tartu’s General Health Insurance Fund ended 1938 in the red, which was partially due to an outbreak of the mumps at the end of the year. The health insurance fund was forced to reduce its expenditures and thus it decided to stop paying sickness benefits for Sundays and holidays.
The foundation of the health care system in the Republic of Estonia was the system implemented in tsarist Russia, where most health care institutions were either established and run by enterprises or were private practices and private hospitals. According to legislation that went into effect during the brief period of Soviet rule, enterprises were required to hand health care institutions over to health insurance funds and several institutions managed to do so.
Prior to the Soviet occupation in 1940, the evolution of the health care system in the Republic of Estonia resembled the way health care was set up in Western European countries. Three types of hospitals emerged in Estonia in its hospital system, providing medical care round the clock: private hospitals, municipal hospitals for the poor, and publicly owned hospitals. Maternity and paediatric clinics, tuberculosis treatment centres, and sanatoriums and medical institutions for the mentally ill were publicly owned. Primarily dispensaries belonging to the health insurance fund, contractual private physicians, and private physicians working in schools provided ambulatory care. Larger enterprises had dispensaries that provided care for their employees and members of their families. Municipal physicians with salaries paid by the public sector worked in rural counties and provided medical care mostly to the less affluent population.
People in need of medical attention had no opportunity to choose their physician. That was determined by the health insurance fund agreement. If anyone wanted to