Estonia's family medicine system faces several challenges, including an aging physician workforce, limited recruitment of new doctors, and regional disparities in access to care.

As a solution, abandoning the patient list system and removing ownership restrictions in family medicine have been proposed. These two proposals are often discussed together, even though they are, in substance, two different issues. The patient list system concerns who is responsible for patients. Ownership determines who controls the organization providing the service and what objectives shape its management.

Patient lists provide accountability and continuity of care

The patient list system creates a clear link between a patient and a specific family doctor. This is an important strength of Estonia's primary health care system. A 2026 report by the WHO Regional Office for Europe found that an ongoing relationship with the same primary care physician or a small care team is associated with lower mortality, fewer emergency room visits, and fewer hospitalizations.

Continuity is especially important for people with chronic diseases, mental health conditions, and complex social needs. For patients with routine or acute concerns, rapid access to care may sometimes be more important than seeing their regular doctor. Family medicine centers can organize care in a way that provides quick access when needed while maintaining long-term doctor-patient relationships where they have the greatest impact.

In Estonia, the owner of a company providing family medicine services can be either a family physician or a local government. Proponents of removing that restriction argue that it would free family doctors from management responsibilities. Physicians should indeed be able to focus on clinical work. However, ownership and management are two different things. A physician owner does not have to manage the practice on a day-to-day basis. A manager can be hired, support services can be centralized, and a larger organization can be built without changing the ownership structure.

In health care, the owner's profile is particularly important because not every decision affecting service quality and the organization of care can be specified in advance through contracts. Service providers always retain a degree of discretion, and how that discretion is exercised, and what choices are made, is influenced by the owner's objectives.

A comparative study of five countries published in 2026 found clear differences between health care professional owners and financial investors. For a physician owner, the practice is often both a day-to-day workplace and a life's work. The company's profits may remain as the physician's income or be reinvested in the development of the practice.

Concerns over investor ownership

A financial investor has different objectives. Investors typically place money in a company on a temporary basis, seek to increase its value, and/or intend to sell their stake later at a profit. This can also affect how a family medicine center is managed, which costs are cut, how work is organized, and what services are offered to patients.

When discussing ownership, the focus is often primarily on profits and dividends, but in the case of a financial investor, that is too narrow a view.

Money can also flow to the owner or related companies through rent, loan interest, management fees, and other payments. For example, a health care provider may sell its real estate to an investor and then continue leasing it on a long-term basis. This may free up capital for investments, but at the same time creates an ongoing rental obligation. If that cost becomes substantial, less money remains available for employees and service development.

Private equity transactions have grown rapidly in health care, and investments are often made in outpatient services (OECD analysis). At the same time, little information is available about the actual owners, the transactions, and their impact. The situation is similar in Estonia. The Health Insurance Fund focuses primarily on purchasing and financing services, not on disclosing providers' capital structures, lease obligations, or payments to related parties.

Market concentration matters

Family medicine is not a typical service where, if one company leaves the market, another provider simply steps in to fill the gap. If a provider runs into difficulties or ceases operations, care must still be guaranteed.

According to the 2026 study referred to above, a private equity investor typically enters a company for a defined period, with the aim of increasing its value and selling its stake a few years later at a profit. This is the standard business model of such investors.

The need for family medicine services is not temporary. People need their family doctor both today and 10 years from now. For that reason, it is necessary to assess whether the owner's interests and time horizon support the long-term stability of the system.

For example, in the Netherlands, the large family medicine chain Co-Med encountered financial difficulties in 2024, raising questions about the sustainability of services and the need for oversight of investor-owned providers.

Another example comes from Lithuania, where InMedica grew from 18 primary care clinics to a network of more than 80 clinics in six years. During that period, the company completed 27 additional acquisitions, and more than 310,000 people, or over one-tenth of Lithuania's population, used its services. This is a typical growth strategy for private investors. In addition to family medicine, the company expanded into diagnostic and specialist care services, gaining increasing influence in the market. In 2021, Lithuania's Competition Council found it necessary to intervene and impose conditions on further market concentration, and in 2025 the network was sold to a Finnish group.

The Estonian market is small. What happens if a large share of the country's already scarce family doctors comes under the control of a single owner? The larger one company's role becomes, the more patients, the Health Insurance Fund, and the state depend on it. At a certain point, potential failures by such a company are no longer solely the owner's concern. International literature uses the term "too big to fail" to describe a company that becomes so important to the system that the public sector must intervene to ensure continued services if difficulties arise.

Significant market power can also affect negotiations with the Health Insurance Fund and create additional pressure for higher prices. Furthermore, as in the Lithuanian example, expanding the range of services offered also creates an economic incentive to direct patients to other services within the same company, which may not always serve the interests of patients or the public.

Private capital will not bring family doctors to underserved areas

Changing ownership will not solve the shortage of family doctors, create more trained family physicians, or ensure that access improves in the areas where it is most needed. Investors prefer areas with larger patient populations and stronger economic returns, primarily urban areas. That is understandable because investments are expected to generate returns.

Research also points to the risk that greater attention may be given to more profitable services and patient groups, while activities that are less profitable but socially necessary may receive less attention.

For that reason, removing ownership restrictions cannot be seen as a solution to regional shortages of family doctors. Improving access in less populous or more difficult-to-serve areas requires adequate funding, contract terms, and service obligations.

Family doctors must be, and already are, able to work as salaried employees if owning a company is not of interest to them. It is also worth discussing whether the circle of health care professionals eligible to own practices could be broader than it is today.

The role of local governments also deserves greater attention. The perspective of a local government differs from that of a financial investor. A municipality is interested in ensuring that family medicine services remain available in its area 10 or 20 years from now. At the same time, it is responsible for social services and much of the organization of local well-being.

If Estonia moves toward greater regional responsibility and closer integration of health and social services, the role of local governments in organizing family medicine may become more important, as has happened in other countries.

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