TALLINN, 10 November 2016 – In the opinion of the National Audit Office of Estonia, the current health care administration of children requires prompt changes, because illnesses affecting children are not discovered early enough, children do not receive treatment on time and the treatment is not always consistent. Untreated illnesses will be reflected in the future in the loss of years of life and work of the working-age people, thereby directly affecting the overall functioning and coping of the state. Health care administration can be improved upon by establishing a substantive cooperation between health care specialists and by appointing a party whose task it is to ensure that a child receives help at the right time.

Health problems go undetected. The state has prescribed medical examinations at specific intervals for early discovery of illnesses. The audit indicated that children undergo medical examinations irregularly and that it depends on the age of the child. Children up to the age of 2 years old of whom 85–93% underwent the family physician’s medical examination with the prescribed frequency undergo medical examinations the most.

Preschool-age children at the age of 3–6 years old should undergo medical examinations at least once a year. Less than 4% of preschool-age children underwent medical examinations at that frequency. Over three years, half the children in this age group never underwent medical examinations, which mean that some children may be off the health care employee’s radar.

Children undergo medical examinations the least when they are school-age: 8–20% of children underwent examinations, depending on their age.

There are different reasons for why children do not undergo medical examinations. One reason is that the Ministry of Social Affairs has not been able to effectively make people aware of the necessity of medical examinations. Many family physicians have also not paid separate attention to children’s medical examinations. Due to poor awareness, parents are still widely of the mindset that going to the doctor is not necessary before the onset of an illness. Children of parents with this mindset tend to see a specialist too late when the health problem has already aggravated. As a result, treatment time extends, the risk of complications increases, the child is removed from active life and monetary burden on the health care system increases.

In the opinion of the National Audit Office of Estonia, it is also necessary to analyse whether or not the number of times prescribed for medical examinations is optimal or whether or not there are certain exaggerations.

The second bottleneck that impedes the early detection of health problems is the organisation of school health care in Estonia. Because a school-age child spends a large part of their day in school, both health promotion and monitoring of health should be a part of the school life for all children. The audit indicated that 14 schools lacked the school health care service. The established requirement of one school nurse per 600 students was not complied with everywhere, i.e. approx. 34,000 school children did not receive the required school nurse care.

Many educational establishments also lack necessary academic advising specialists that would know how to detect problems, incl. mental disorders, and help the child. For example during the academic year of 2015/2016, less than third of the general education schools had a special education teacher or a school psychologist. Less than half of the schools have a speech therapist. Because academic advising specialists are generally unable to stand in for one another, children’s health problems are not detected in many schools before they have already aggravated.

One reason for the lack of school nurses is due to the fact that the Health Insurance Fund finances the school health care service only for 11 months out of the calendar year, i.e. the school nurse is only paid for 11 months. At the same time, a nurse working in the hospital generally earns a higher wage and does so for all 12 months. Academic advising specialists have also pointed out that one reason for the lack of interest in the work are the low wages.

Children do not get treatment on time. Because a health problem is not detected or diagnosed on time, children are not sent to see a specialist where the child could get the necessary help. In cases where the health problem was detected and the child was sent on to see a specialist, the child did not always make it to see one.

The analysis carried out by the National Audit Office of Estonia indicated that in the year 2014, school nurses sent children needing medical care mostly to see an ophthalmologist, dentist and family physician. 48% of the children sent to see a specialist made it to an ophthalmologist’s appointment, 65% to a dentist’s appointment and 41% to a family physician’s appointment. Half of the children sent to see a doctor in whom the school nurse had detected a health problem never made it to see one. The reasons for this were poor availability of specialised medical care (distance, long waiting lists), insufficient exchange of information between specialists and parents, and the lack of awareness and/or disregard among the latter.

The National Audit Office of Estonia in cooperation with the Estonian Psychiatric Association also analysed the treatment of children suffering from eating disorders and activity and attention disorders who were receiving hospital treatment due to their health status.

The results of the analysis indicated that 32% of children had received medical care on time, incl. 29% of children suffering from activity and attention disorders and 37% of children suffering from eating disorders. As such, the problem was not diagnosed on time in two-thirds of the cases. Due to late discovery, treatment commenced on average two years after the first documented symptoms.

Treatment of children affected by illnesses is not always consistent. The audit indicated that if a health problem is diagnosed and the child also makes it to see a doctor, he or she may not always receive medical care to the required extent. Among obese children, for example, over a period of four years, 30% of the target group received health service for two years, 8% for three years and 4% for all four years. Treating an obese child, however, presumes receiving regular health service in order to ensure the effectiveness of the treatment. One reason for irregular treatment is the lack of case management approach, i.e. there is no party in the system that would make sure that the child sees the required specialist. On the other hand, careless attitude of parents with regard to complying with the treatment scheme and lack of awareness regarding health behaviour is also a reason for it. First illness among obese children has increased by 54% over a period from 2006 to 2014.

In summary, the results of the audit indicated that monitoring the health of the child and the provision of health services is not functioning in a coordinated and patient-oriented manner.

In order to improve the organisation of maintaining the health of children and treating children, family medical care, school health care service, specialised medical care and academic advising service shall have to be combined into a functioning and coordinated network in a better manner than it is presently. In doing so, a prerequisite for functioning is that the system includes a specialist serving as a case organiser whose task is to continuously monitor whether or not a child is sent to see a health care provider and whether or not the child receives the required services. If necessary, the case organiser shall draw the attention of the parent and/or child protection to the fact that the child has not received one or another health service necessary for the child.

The Auditor General Alar Karis said: “Liability for the welfare and health of the child lies with the parent, but the state cannot allow for children whose parents are unable to or do not know how to care for the health of their children themselves to be left without attention or help. For example, the number of irresponsible parents who have refused to vaccinate their children has grown, endangering both the health and life of their child, and at the same time putting the health of other children with whom the unvaccinated child comes into contact in risk.

In order to prevent health risks from realising and to manage health problems, attention has to be paid to the health of children already from the moment of birth. This is foremost possible by way of preventing illnesses through medical examinations and vaccinations, but also through promoting health by teaching both children and parents how to live a healthy lifestyle.”

Background

• According to the data of Statistics Estonia, approx. 258,000 up to 18-year-old children were living in Estonia in 2015, constituting 20% of the population. Over the last 10 years, the number of children has decreased by nearly 30,500 children, i.e. by approx. 11%.
• Onset of benign tumours (63.4%), bronchial asthma (61%) and eating and metabolic disorders (57.3%) among children have increased the most. The most common reasons for these are unhealthy eating, lack of exercise and risks arising from the growing environment.
• In 2006–2014, the number of overweight children has grown from 7.4% to 11.3%.
• According to the international study HBSC (Health Behaviour in School-Aged Children), Estonian children eat much less fruits than elsewhere, try alcohol, tobacco and marijuana earlier and exercise less.
• According to the UNICEF study completed in 2016, children from the poorest families in Estonia have 28% more health complaints in comparison to children from wealthier families.

Toomas Mattson
Head of communications of the National Audit Office of Estonia
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• Posted: 11/10/2016 11:00 AM
• Last Update: 11/10/2016 12:08 PM
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