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28 July 2025 | Country Update
Unsuccessful development work of e-ambulance -
10 February 2025 | Country Update
National Audit Office report identifies several bottlenecks in Estonia’s ambulance services
5.5. Urgent and emergency care
Everyone in Estonia (residents, non-residents, tourists) is entitled to receive ambulance services, which are defined as outpatient health services for the initial diagnosis and treatment of life-threatening diseases, injuries and intoxication and, if necessary, transportation of the person requiring care to a hospital.
Until 2017, ambulance services were financed from the state budget. As of 1 January 2018, the expenditure on ambulance services is part of the EHIF budget and the EHIF fully finances, procures and contracts ambulance services, similar to most other health care services (see also section 3.3.4 Purchasing and purchaser–provider relations). The MoSA sets the price list and the Health Board remains responsible for the organization of ambulance services in Estonia and, on this basis, approves the number and location of service areas and the location of ambulance crews based on that. Ambulance services remain free of charge at the point of use.
The transfer of the ambulance services to the EHIF was part of the larger reform that started in 2018. This reform is expected to lead to efficiency gains, as the services provided by ambulances, family physicians and hospitals were weakly integrated, partly because organization of the services fell under different authorities (see section 6.1.1 Streamlining the roles and responsibilities of health sector agencies).
Since 2018, amendments to the Health Services Organization Act and a ministerial decree have regulated the contracts between the EHIF and ambulance service providers. The owner of the ambulance crew must hold a licence from the Health Board and can be a company, a private entrepreneur, a foundation, or a state or local government rescue service agency. A legal ambulance service organization may only provide emergency medical care. Hospitals are exempt from this rule. The government establishes the procedure for cooperation in the provision of emergency care between the emergency medical staff, hospitals, the Estonian Rescue Board and the police authorities; the MoSA determines the number of ambulance crews to be financed. The EHIF is entrusted with monitoring the quality of emergency care services and providers (see section 2.2.1 The role of the state and its agencies).
In 2023, there were 10 ambulance service providers contracted by the EHIF. The number of ambulance crews has increased, from 90 in 2011 to 104 in 2023. All contract volumes (planned and actual) and details are visualized and publicly accessible via the EHIF webpage. Contract volumes are based on: (1) the number of ambulance crews and their composition (nurses or physicians); (2) the volume of transport services and training of staff; and (3) the volume of teleconsultations. The maximum duration of the contract is five years (see section 3.3.4 Purchasing and purchaser–provider relations).
Crews are concentrated in the more densely populated areas. In some cases, air transport (the planes and helicopters of the Police and Border Guard Board) is used for emergencies on the small islands.
There are three different types of ambulance crews: (1) a mobile intensive care unit led by an emergency medicine physician or an anaesthesiologist; (2) a medical team led by an emergency medicine physician, an anaesthesiologist or a general practitioner (with at least 40 hours of emergency medicine training); and (3) a nursing team led by either an intensive care nurse or an emergency nurse or a nurse with an additional 240 hours of emergency training. The crew also includes a nurse or emergency medical technician, and an ambulance technician who is licensed to drive an ambulance. Most ambulance crews in Estonia are nurse-led. If necessary, mobile intensive care units or doctor-led crews provide assistance and manage the transportation of critically ill patients from one hospital to another. There are also voluntary ambulance crews, each consisting of two volunteers, stationed on four small islands, where it is neither financially viable nor are there enough personnel to establish common ambulance crews. Additional ambulance crews with reduced staff have been established by order of the Health Board to respond to the increasing number of calls. The extra crews were added mostly in response to the increase in patients with COVID-19, but they were also used to carry out COVID-19 testing and for other reasons.
The emergency call centres function under the Ministry of Internal Affairs. The task of the call centre staff is to prioritize incoming calls according to the guidelines of the Union of Estonian Medical Emergency. In a life-threatening situation (called “D” or Delta priority), the crew is sent out within one minute. “C” or Charlie priority describes a severe health status of the patient and the crew is deployed within four minutes. Calls “B” (Bravo) and “A” (Alpha) have a lower priority, so the crew will be dispatched to see those patients within two hours. In 2021, the emergency call centre received 307 780 calls, 10% more than in 2020 (EHIF, 2021b). In addition, ambulance services will also be involved in improving the pathway for stroke patients and other chronic patients, in order to secure sufficient emergency care at the first point of contact (see Box5.2).
Box5.2
In 2020, the COVID-19 pandemic prompted a redefinition of the roles of health service providers in emergencies, as well as national defence and preparedness levels. The existing regulation was deemed inadequate for the pandemic response, as it focused primarily on trauma-related crises, had limited flexibility, lacked a comprehensive health system perspective and missed crisis management structure. Consequently, a new regulation came into force in November 2020, tasking the Health Board with developing a central crisis management structure for PHC. The COVID-19 pandemic showed that the decentralized nature of PHC service provision makes it difficult to reorganize quickly, and that a centralized crisis management structure was needed.
In April 2022, a public procurement was launched to analyse the person-centred pre-hospital emergency care in Estonia. The analysis included three sub-topics:
- to study the current organization of the emergency medical care service;
- to describe best practices of pre-hospital emergency medical care in other countries and compare them with Estonia; and
- to prepare three policy scenarios for the development of pre-hospital emergency medical care in Estonia.
The MoSA commissioned the analysis, which was completed in 2023. Based on the findings, the Ministry will collaborate with stakeholders to develop a plan for the ambulance system for the next decade.
The current e-ambulance solution serves as a digital tool for ambulance crews, allowing them to access real-time patient health information and document their actions when resolving cases. However, this system is becoming outdated, prompting the Estonian Health Insurance Fund (EHIF) to launch a tender in 2022 for a new e-ambulance system.
The planned new system aimed to provide user-friendly documentation and more intelligent support for ambulance operations. Its key objectives included enhancing technical quality, developing a simple and functional user interface, enabling telemedicine consultations across all Estonian ambulances, integrating equipment for automatic data exchange, offering essential support for medical decision-making, and streamlining the future adoption of innovative features.
Unfortunately, the original deadline for the updated e-ambulance, February 2025, was missed. The developer then proposed an alternative solution by summer 2026, but EHIF rejected this due to significant cost increases and a determination that it would not meet specific needs. Consequently, the contract with the procurement partners was terminated by mutual agreement after a thorough evaluation of the project’s sustainability. Both parties concluded that continuing under the existing terms would not have led to the desired outcome.
This termination resulted in a substantial financial loss. In total, 1.1 million euros had been paid for the project. Following negotiations, EHIF managed to recoup approximately 750,000 euros, leaving a final loss of 350,000 euros.
Looking ahead, EHIF will announce a new tender, incorporating lessons learned from this unsuccessful experience. Importantly, the contract’s termination will not impact daily ambulance operations or patient safety, as the current digital solution remains active.
Authors
The National Audit Office (NAO) report on ambulance care organization (issued in January 2025) found that the Emergency Medical Service (EMS) is frequently used for non-critical situations that could and should be handled by family physicians or social workers [1]. The audit highlights that the Health Board, which is responsible for the organization of ambulance services in Estonia, and the nationwide Emergency Response Centre, which processes emergency calls, do not systematically analyze how ambulance calls are managed. Additionally, EMS is often used to transport non-urgent patients between hospitals, increasing the risk that life-saving assistance may be delayed for critical cases because crews are occupied elsewhere.
In addition, the NAO found that the Health Board has taken a passive role in acting to improve the planning, organization and supervision of the EMS when it comes to resolving or preventing problems of inappropriate use of the EMS. The Estonian Health Insurance Fund, responsible for purchasing the EMS services, has delayed holding a public competition for ambulance service providers for over a decade without documented justification. The NAO report suggests for the Ministry of Social Affairs to take more action in developing a clear vision of the needs of the ambulance service in Estonia, including developing more decisive control over the field, as currently tasks and responsibility are fragmented. It also proposes legislative changes and IT developments that would improve the integration of the health and social care systems, helping to avoid inefficient use of ambulance services, where transport could be provided by hospitals, social workers or local authorities.