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Estonia covers an area of 45 227 km² in the Baltic region, bordering the Russian Federation in the east and Latvia in the south. The population is 1.34 million. Administratively Estonia is divided into 15 counties, over 194 rural municipalities and around 33 towns. Estonia is a parliamentary democratic republic.

In 2004, Estonia became a member of the North Atlantic Treaty Organization and of the European Union.

Health and health-system

Disease pattern changes, with new challenges ahead

The infant mortality ratehas decreased substantially (from 15.7 in 1992 to 5.0 in 2007) and has remained very low in recent years. The average life expectancy is 73.9 years and has been increasing steadily, but with a gap of almost 11 years between men (68.6 years) and women (79.2 years). The main disease burden challenge is premature mortality caused by external causes and lifestyle-related risk factors. The working-age population bears more than half of the disease burden (60% among men). Similar to other industrialized countries, the main causes of mortality are diseases of the circulatory system (50%), cancer (20%) and external causes of death (10%). Mortality differs between men and women due to differences in mortality from external causes. Mortality from circulatory diseases is higher among men than among women. The lifestyle risk factors causing the disease burden are alcohol consumption, use of tobacco, low physical activity and low intake of fruits and vegetables. A growing challenge is the increasing prevalence of obesity. In the past decade, a new challenge of tackling communicable diseases such as HIV and multidrug-resistant tuberculosis has emerged. Estonia has one of the highest HIV incidence rates in the WHO European Region. Estonia has kept other communicable diseases under control with broad vaccination programmes implemented with high coverage.

Health system reform

Estonia has rapidly and successfully reformed the health system over the past 18 years. The reforms started with health system financing, followed by organizational changes in service delivery and overall governance. During the transition, Estonia’s economy developed rapidly and sequential health system reforms were implemented.

Health system financing

In 1991, Estonia established a mandatory social health insurance system financed by income-related contributions and covering almost the entire population. The health insurance system went through various changes from decentralization to recentralization. Currently, a single health insurance fund is responsible for collecting contributions, pooling and purchasing health care services. Discussions continue as to whether a similar active purchasing function should be established for public health services. System-wide cost containment and improvements to the efficiency of the health system have always been driving forces in the health care financing reforms. The financial protection of the population has remained an important objective, but private funding from households has increased over the years and is currently at the level of the western European countries.

Health care services

Health care was reshaped at the primary care level around family physicians, who have a partial gatekeeping role with direct access to a few selected specialists and a coordinating role. Currently, the whole population is covered by a network of family physicians and enrolled with individual family doctors. In parallel to primary care reforms, access to essential and modern medicines has improved over the last decades. Restructuring of the hospital sector has complemented the reform of primary health care. Estonia has succeeded in significantly reducing the excess capacity of acute care hospitals to the average level of the European Union. The challenge is developing a network of long-term care providers and improving collaboration between the levels of care. The public health system has been decentralized, and several networks have been created to empower citizens. Standardizing public health services and strengthening coordination continue. Several organizational models have been applied to improve risk management in health protection. In disease prevention and health promotion, links have been applied to primary care and empowerment of nongovernmental organizations to increase the possible service delivery networks.

Stewardship

The Ministry of Social Affairs has exercised stewardship through various policy documents, strategies and regulations. An institutional framework includes various agencies and institutions under both public and private regulation. European Union accession has increased the need to improve coordination at country and international levels. Further, the need for health sector leadership to exert influence over other sectors has increased. For this, new leadership and management practices need to be developed and clear performance measurement applied to achieve the health system goals. In 2008, the Government approved a national health plan 2009–2020, which aims to increase the health status and quality of life of the entire population.

Human resources

Human resources have been developed over the years. Training institutions have been upgraded using quality criteria, and new curricula have been implemented for nurses and doctors. Nevertheless, the ratio of doctors and nurses still does not favour shifting tasks and responsibilities and exercising new models of care. The continuing education activities for health professionals and quality management mechanisms have not yet been implemented fully. New challenges have emerged since European Union membership, motivating the workforce to remain in Estonia.