Dear reader!
This year marks the passing of 20 years since the re-establishment of health insurance in the Republic of Estonia. That is a sufficiently long time to look back and recall how we have arrived at the present day.
We all tend to forget, especially those events and activities that do not have to be recalled every day. That is why we asked those people whose ideas have been implemented over 20 years and who have contributed to the development of our health system to recall their activities and write them down. This book does not aspire to absolute truth or precision in terms of facts, the aim is rather to present people’s memories as genuinely as possible.
As we read this book, we see that quite a lot of what was initially agreed on has been implemented over the course of 20 years. Diligent and persistent people have led the health care sector, and intense activity has carried on continuously. People’s way of thinking has changed over the years and the centre of gravity of thoughts and ideas has shifted in a definite direction. The initial objective of reorganising medical institutions and their financing has given rise to aims intended for patients and brought aspects associated with human values to the surface: solidarity, insurance coverage and the ability to pay for necessary health care expenditures. I am happy to say that this development has proceeded in the right direction and our current objective is to ensure that people receive high quality and timely medical care in the event that health problems arise.
I thank everyone who has contributed to the completion of this book with their advice and assistance and I wish pleasant reading!
Hannes Danilov
Chairman of the Board of the Estonian Health Insurance Fund
I
Development of Health Insurance: 1912–1991
Otto von Bismarck.
The history of sickness insurance extends back to the 19th century when the first sickness insurance act was passed into law in Germany in 1883 at the initiative of Otto von Bismarck. Why was this necessary?
As industry evolved, industrial accidents became more serious compared to agricultural accidents and independent entrepreneurs were no longer able to pay for the treatment of workers to the extent that was necessary. It was, however, necessary to treat workers because due to the specialised nature of work, manpower became increasingly more valuable. Then the idea of centralising means by way of insurance payments emerged as a way of spreading out the risk of medical treatment expenses. Naturally, workers also demanded that manufacturers improve working conditions and cover medical treatment expenses in the event of accidents. Bismarck’s aim was nevertheless not only the better organisation of the treatment of industrial workers but also to improve cooperation and communication between manufacturers and workers’ health insurance funds.
The health insurance act created in Germany encouraged the workers of other countries to fight for their rights as well. Tempestuous events unfolded in all the major countries of Europe. In France, the first health insurance act was passed in 1894, whereas it was compulsory to insure miners. The laws passed in Italy, Belgium and Switzerland in 1910 also insured all women between the ages of 15–50, while the law passed in England in 1911 insured all workers over the age of 16.
The rulers and industrialists of tsarist Russia did not escape the workers’ growing pressure to change working conditions and the ordering of the affairs of the lives of workers either. During the revolution of 1905–1907, workers demanded, among other things, that the tsarist government provide insurance for old age, disability and illness. The Duma worked out the fundamentals for state insurance in 1905 already and draft legislation for health and accident insurance (HÕKS) was deliberated for the first time in 1908. The deliberation and reworking of the draft bill was an arduous process. The State Council of tsarist Russia did not approve the fundamental principles of health and accident insurance within the framework of the Russian Industrial Labour Act until 23 June 1912. According to the new law, health insurance funds were to be created at industrial enterprises with at least 20 workers where machine power was used. All businesses with fewer workers, as well as handicrafts enterprises were not subject to this law.
The establishment of health insurance funds began in 1913. In May of that year, six health insurance funds supposedly existed in tsarist Russia. By July of the same year, there were already 66 such funds. Tsarist health insurance was in effect in tsarist Russia for exactly five years. On 25 July 1917, Russia’s bourgeois Provisional Government passed an amended health insurance act that prescribed the complete local self-administration of health insurance funds and required the creation of health insurance funds for enterprises with at least five workers. The complete self-administration of health insurance funds also meant that workers founded and managed health insurance funds, and the owners or managing directors of enterprises were not included in the management of the funds. Additionally, the types of business covered by sickness insurance were also expanded. After the October Revolution, enterprises had to hand medical establishments over to health insurance funds as well because it was felt that health insurance funds run by workers would be good managers of hospitals and dispensaries.
Prior to the work of health insurance funds, there was no definite law or ordinance in Estonia that would have prescribed financial assistance to workers in the event of their illness, or financial assistance for parturient women, or support in the event of the death of a family member. Since laws passed by the Russian Duma were in effect in Estonia, the insurance act of 23 June 1912 was implemented here and the creation of health insurance funds began. In March of 1913, representatives were elected to create a health insurance fund at the Sindi Broadcloth Manufacturing Association factory and at three enterprises in Tallinn – the Baltic Cotton Textile Mill, and the Wiegand and Volta factories. In May of the same year already, the representatives managed to put together a draft statute for the health insurance fund.
Wiegand Factory Health Insurance Fund statute of 1913.
The Tartu General Health Insurance Fund was founded on 23 June 1912 at Tartu’s largest industrial enterprise and is one of Estonia’s oldest health insurance funds, yet it nevertheless did not begin operating until 1 May 1914. This is why the health insurance fund founded at the Sindi Broadcloth Manufacturing Association (formerly Wermann and Son) factory is considered to be the first health insurance fund, the statute of which was approved on 15 May 1913. A few months later on 20 September 1913, the Baltic Cotton Textile Mill health insurance fund was created. The statute of the health insurance fund at Volta Ltd. was approved on 2 October 1913. By the end of that year, health insurance funds had been created at the Wiegand, Luther, and other factories. The Luther factory health insurance fund statute states that its general meeting and its board of directors ran the activity of the health insurance fund. The general meeting consisted of deputies of health insurance fund members and representatives of the enterprises. The chairman of the board of directors was the owner of the enterprise or a person appointed by him. A representative of the employer chaired general meetings of deputies. Deputies appointed by the representative of the employer had 2/3 of the votes of the participants at the meeting. The Tallinn Municipal Health Insurance Fund was founded on 21 March 1914. It insured the workers and employees of three enterprises – the gas plant and waterworks, the electric power station, and Tallinn Horse Tramway Ltd. The demand by factory workers to found a common health insurance fund for all of Tallinn’s factories did not gain the approval of employers. A large association of workers in the form of a common health insurance fund was not welcome in Tallinn as a large industrial centre because it was feared that it would be easy to direct other workers’ events and the general workers’ movement through this common fund.
K. Mauritz, Chairman of the first Board of Directors of the Tallinn Municipal Enterprises Health Insurance Fund.
In subsequent years, the number of health insurance funds grew rapidly. In 1914, 22 health insurance funds began operating. In 1915, there were 33 health insurance