5. Provision of services
The Estonian public health system is a decentralized multistakeholder system where emphasis has shifted towards disease prevention, health promotion and addressing the determinants of health. Various structural and managerial reforms since 1990s have been aiming to establish primary care at the centre of service delivery. Primary care is the first level of contact with the health system and is provided by independent family doctors working solo or in groups and practising on the basis of a practice list. More recent reforms aim to strengthen primary health care by establishing health centres through incentivizing mergers between solo practices that provide a wider scope of primary health care services. Secondary care health services are provided by publicly or privately owned health care providers (hospitals and outpatient care clinics) operating under private law. The HNDP network consists of 20 hospitals which are favoured in contract negotiations with the EHIF and have been major recipients of capital investments from the EU Structural Funds. Still, the number of hospitals is high and sustainability of smaller county level hospitals is a serious concern. The state has been supporting hospital networking, where bigger hospitals establish a formal cooperation with smaller hospitals (see section 4.1.2 Infrastructure). During the last decade nursing care and rehabilitation have been becoming more important and several steps have been taken to increase access to these services, including improved legislation, additional funding and promoting a bigger role for nurses and mid-level health professionals in care provision. Ambulance services are purchased by the EHIF and provided by ambulance crews, ensuring that everyone in Estonia receives emergency medical care. Pharmaceuticals are distributed to the public through privately owned pharmacies. Estonia is in the process of reforming ownership rules by prohibiting wholesalers and health care service providers to own pharmacies and requiring that all pharmacies are owned by pharmacists.
5.1 Public health
5.1.1 Public health governance
The Estonian public health system has been reformed from the centralized sanitary-epidemiological system, where focus was mainly on enforcement and control, to a more decentralized multistakeholder system in which the emphasis is on disease prevention, health promotion and addressing the determinants of health. The reforms began with the Public Health Act in 1995, which laid out tasks and responsibilities in the field of public health. The Act has been amended frequently over the years and since the mid-2000s there have been plans to introduce a new Public Health Act that would clarify the fragmented roles and responsibilities of national, regional and local counterparts. The preparatory process of the new Act is currently ongoing (2017) and has been delayed due to an ongoing public administration reform that started in 2015 and is planned to finish in 2018. This reform will reduce the number of local governments. The government will also increase funding of local governments over the period 2017–2020, which should increase their capacity and improve their services, in the area of public health as well as other areas.
The Ministry of Social Affairs acts as the steward and governing body in public health. Other main national actors in public health are the Health Board, the NIHD, the EHIF, the Labour Inspectorate, the Ministry of the Environment, the Environmental Inspectorate and the Veterinary and Food Board under the Ministry of Rural Affairs (see also Chapter 2).
At the regional level, public health has been coordinated by county governments since 1996. Each County Government has employed a health promotion specialist and has formed a County Health Council, which acts as a regional link between the national and municipal level, and coordinates county-specific health promotion efforts. The current public administration reform plans to abolish county governments by 2018. County level obligations previously held by county governments will likely be given to local municipalities. All municipalities in one county will jointly be responsible for county-level public health actions and will choose a body to carry out the necessary actions. These obligations will be stipulated in the current Public Health Act and come into force in 2018 (see also subsection Community-based health promotion in section 5.1.4 Health promotion).
The current Public Health Act also establishes the role of single municipalities and states that municipalities in Estonia are required to monitor whether health protection legislation is being adhered to and implemented in their territory. Furthermore, they must coordinate local activities concerning health promotion and prevention of diseases. The new Public Health Act should further establish and clarify the roles of single municipalities regarding public health. This includes an obligation to monitor the state of their population’s health and well-being, plan and implement health-promoting actions according to the local public health situation and form the necessary networks in order to do so.
The main planning tool for national public health efforts is the NHP (Ministry of Social Affairs, 2008, and updated in 2012). The plan covers all health-related fields, including health promotion, disease prevention, health protection and health care. In 2017 an independent evaluation concluded that domain-specific national action plans should be restored if health system governance is to be improved (see more on this topic in section 7.6 Transparency and accountability).
5.1.2 Surveillance of population health and well-being
Information about the health status of the adult population has been collected from several surveys: the Estonian Labour Force Surveys, the European Social Survey and the Estonian Social Survey. In these surveys, the health questions have often been limited and study-specific. Starting from 1990, more detailed information about various health behaviours and data on the health status among the adult population have been collected through three main studies – these are the Estonian Adult Population Health Behaviour Study, which takes place biannually, the Estonian Health Interview Survey (1996, 2006, and 2014) and the Survey of Health, Ageing and Retirement (SHARE).
Two studies addressed children and adolescents, that is, Health Behaviour in School-Aged Children (HBSC) and the European School Survey Project on Alcohol and Other Drugs (ESPAD), using the school years 1993/1994 and 1995 respectively.
The majority of data from these studies are published by the NIHD, which serves as the competent body for health statistics in Estonia. The NIHD is also responsible for the regular submission of Estonian health statistics and health care statistics to international organizations. All national health data are published in the national health statistics and health research database (www.tai.ee/tstua) (see also section 2.7.1 Health information systems).
5.1.3 Health protection
The Public Health Act (1995), the Communicable Diseases Prevention and Control Act (2003) and several other regulations regulate communicable diseases prevention and control. The surveillance of communicable diseases is organized by the Health Board. The responsibilities related to controlling the spread of communicable diseases are shared with the NIHD, which is responsible for monitoring of HIV and TB. National disease registries (except the communicable disease registry) are a responsibility of NIHD, including the National TB Registry.
Several communicable disease prevention and control activities are not well integrated into the general health system. Because the national public health programmes and policies in the 1990s and early 2000s were disease-based, some communicable diseases (HIV, TB, sexually transmitted diseases (STDs)) were monitored through special national programmes, rather than the general health system. Though these disease-specific and outcome oriented national programmes have been successful and have remarkably reduced the spread of these communicable diseases, the current challenge is to integrate these activities into common health system practice.
Surveillance of communicable diseases is built around the Estonian Communicable Diseases Information System, which requires family physicians, medical consultants and laboratories to report 59 communicable diseases and 91 etiological agents. The data are stored nationally at the Estonian Communicable Diseases Registry, effective since October 2009. The electronic system has reduced the time lag in reporting, since the proportion of paper-based reporting is gradually decreasing (in 2015, 61% of all notifications were electronically reported). If there is a serious infectious disease or suspicion thereof, telephone and email reporting is used.
Estonia has a mandatory countrywide reporting system for communicable disease outbreaks. The suspicion of outbreaks has to be immediately reported to the Health Board. Protocols specify the response to epidemic outbreaks for 59 diseases. The Health Board investigates communicable disease outbreaks (including foodborne disease with the Veterinary and Food Board) and an obligatory report is prepared. County departments of the Health Board Regional Service are responsible for the detection and investigation of outbreaks of communicable diseases. Investigation procedures include epidemiological investigations, laboratory diagnostics and, if necessary, legal action.
Additionally, in each hospital there must be a doctor or nurse in charge of prevention and control of infectious diseases. Their responsibility is also to assure that necessary guidelines and training are in place and implemented. The Health Board establishes national guidelines and the monitoring system for health care associated infections and antimicrobial resistance control.
Environmental health and emergency preparedness and response
Environmental health is mainly the responsibility of the Ministry of Social Affairs (Department of Public Health), the Health Board and the Ministry of the Environment (among others through the Environmental Inspectorate).
A system of health impact assessment of environmental factors is in place. In accordance with the Environmental Impact Assessment and Environmental Management System Act, a limited number of licensed experts assess the potential impact of objects and activities on human health and well-being. However, the impact assessments are rather general and lack details. Therefore, since 2010, the Health Board has attempted to analyse health threats and risks from the living environment, preparing guidelines for the assessment of the impact of environmental risks on health and informing the general public of health risks.
Water supply, use, quality and sanitation are regulated by the Public Health Act, the Water Act and the Public Water Supply and Sewerage Act. Water surveillance is divided between different ministries and agencies. The Ministry of the Environment is responsible for ensuring and preserving the quality of both ground and surface water. The Health Board has responsibility for protecting the health of the population, and coordinating activities in the area of drinking and bathing water falls. As both food safety and environmental health issues are important parts of the EU acquis communautaire, Estonia’s accession to and membership of the EU has brought about considerable investment in these areas.
The responsibilities and measures with regard to air pollution and noise are regulated by the Ambient Air Protection Act (from 1 January 2017, the Atmospheric Air Protection Act), which, together with specific regulations, covers all requirements set out in the relevant EC directives. The Environmental Inspectorate and the Health Board have shared responsibilities in supervision of the air (respectively, ambient air and indoor air), while noise is solely the responsibility of the Health Board.
Activities related to food safety are regulated by the Food Act. Since 2007, the Ministry of Rural Affairs, with its Veterinary and Food Board, is the leading institution for all major legislation and supervision concerning food, including alcohol. Data, investigations and evaluations are provided for risk assessment via different regular monitoring programmes and laboratory analyses by authorized official laboratories.
The Health Board is also responsible for chemical safety (including detergents and biocides) and cosmetic products. The Poisoning Information Centre was established in 2008 and is now part of the Health Board; it maintains a database with information on first aid and therapy for each type of poisoning and informs the public. A telephone hotline has seen sharply increasing numbers of calls.
The main legislative act in emergency preparedness and response is the Emergency Act, adopted in 2009 to provide a framework for the organization of planning and action during emergencies. There are two specific emergency plans for health that have been adopted by the government. These are the emergency plan related to epidemics and the plan for mass poisoning. For international health regulations (IHR 2005) the focal point is the Health Board.
The Occupational Health and Safety Act (adopted in 1999) regulates responsibilities in the field of occupational health and safety at the state and enterprise level. Employers are responsible for assessing occupational hazards, preparing a written action plan and notifying their employees of risk factors. The Labour Inspectorate is responsible for supervising employers’ compliance with these regulations. The occupational health specialist’s role is to ascertain environmental risk factors at work, conduct medical check-ups and give advice regarding the working environment. Employers have to provide regular medical check-ups for their employees. The Health Board is responsible for the licensing and training of occupational health specialists and participates in the development of occupational health programmes and their implementation.
Occupational health is monitored using various health statistics on working conditions, work-related health conditions and occupational accidents. The employer has to inform the Labour Inspectorate of any incidents, after which an investigation occurs. However, underreporting is of concern.
Since 2008, EU Structural Funds have been allocated to activities to reduce work-related health risks and to promote health in the workplace. The Labour Inspectorate regularly carries out information and consultation activities to raise the awareness of employers and employees about occupational health and safety.
5.1.4 Health promotion
National-level actions in the field of health promotion are mainly focused on capacity-building for communities to improve the health and well-being of people living in their territories. The NIHD is responsible for developing a national support system and national action plan as well as providing counselling, guidelines and other supporting materials and training for health promotion specialists at all levels (counties, municipalities, schools, kindergartens and workplaces). The NIHD also disseminates health information to the public and carries out national health campaigns.
Since 1995, the EHIF has dedicated a certain amount of its budget to health promotion activities approved by the EHIF Supervisory Board and in coordination with the stakeholder committee. These activities have been in line with the national strategic documents. The focus of the EHIF financed activities has changed over time from community development to empowering people in the health care system, e.g. public campaigns to promote rational drug use and development of patient guidelines. Indeed, most of the EHIF’s health promotion funds were previously invested in community development which is currently financed through the state budget and commissioned by the NIHD.
Community-based health promotion
In 1995, the Ministry of Social Affairs introduced a financing mechanism for national and community-based health promotion projects and started training regional community health promotion specialists. Since then, health promotion has been financed from different sources (including the state budget, the EHIF and EU Structural Funds). Since the beginning of 2016, community-based health promotion on the county level was, again, funded solely from the state budget.
With the adoption of the National Strategy for the Prevention of Cardiovascular Disease 2005–2020 (Government of the Republic of Estonia, 2005), the county health promotion network was institutionalized and health promotion specialists were employed by the county governments. County-level health promotion tasks will be handed over to local governments, who will jointly become responsible for fulfilling them (see also section 5.1.1 Public health governance). The county-level duties include compiling county health and well-being profiles (an overview of the health and well-being status and health determinants in the region), implementing activities to improve the population’s health, and creating the networks necessary for the management of public health actions at regional level (e.g. Health Councils).
At the local level, it is the municipality’s task to coordinate local activities concerning health promotion and prevention of diseases (see also section 5.1.1 Public health governance). However, there is still room for improvement in the local response to the needs of the population health status. Since 2009, municipalities and county governments have been encouraged to compile health profiles, develop local public health action plans and increase funding for evidence-based health promotion activities. By 2016, all counties and 71% of all local municipalities had compiled their health profiles, but the level and quality of health-promoting activities still varied substantially.
The financing of community health promotion has gradually been moved from a project-by-project basis to a more strategic planning system. However, the system needs further development and capacity-building to ensure sustainability and equality in capabilities across municipalities, as well as to focus more on health inequities.
5.1.5 Disease prevention
The NIHD is responsible for the implementation of most disease prevention activities as well as some related health services. These activities are planned in the NHP and financed by the state budget as well as from the EU Structural Funds. NIHD activities cover prevention and harm-reduction regarding HIV/AIDS, especially services for people who inject drugs, and HIV voluntary testing and counselling services for at-risk population groups and the general population as well as directly observed treatment for TB. Antiretroviral drugs and drugs for TB are procured centrally by the Ministry of Social Affairs and distributed to health care providers to disseminate them free of charge to patients with TB or HIV/AIDS. The plan is to consolidate drug procurement under the EHIF to reduce the fragmentation and to integrate historical vertical programmes into the general health system. The NIHD is also responsible for smoking cessation services and is currently (early 2018) developing new alcohol dependency early detection and treatment services (developed under the ESF programme and to be integrated in the general health system by 2022). In addition, the NIHD coordinates the screening programmes for breast, cervical and colorectal cancers that are financed by the EHIF. Since January 2015 a cancer screening registry opened under the NIHD with the objective to increase effectiveness, coverage and quality.
The EHIF is involved in disease prevention mainly through the financing of primary health care, particularly regarding medical testing and screening, counselling and immunization, as well as monitoring of pregnancies and chronic diseases. The family doctor quality bonus system covers child check-ups, which include criteria for vaccination coverage and health check-ups in certain age groups (1 month, 3 months, 12 months, 2 years and preschool), as well as check-ups and counselling by family nurses for certain adult risk groups (people aged 40–60 years with hypertension or diabetes) (see section 3.7.1 Paying for health services). Worryingly, family physicians do not consider preventive services their responsibility, and do not see the value of some types of preventive services (World Bank, 2015).
Part of the EHIF budget is specifically dedicated to national disease prevention projects such as youth health counselling on reproductive health; school health services (provided by nurses since 2010) and medical check-ups for young athletes. Some of services which were previously financed as separate programmes are now integrated in the general system, for example neonatal screening for phenylketonuria, hypothyroidism and hearing.
The general legal framework for immunization is laid down in the 2003 Communicable Diseases Prevention and Control Act. The national immunization scheme is defined by a regulation of the Minister of Social Affairs, organized by the Health Board while vaccines are financed by the state budget. Immunization of children is the responsibility of family doctors and school nurses. A committee advises which vaccines to include in the national immunization scheme. Recently, vaccinations against rotavirus, additional revaccination for 15–17 year olds against whooping cough and human papillomavirus were included in the scheme. Immunization rates are gradually declining and coverage among under 2-year-old children has been falling below the WHO recommended level. Immunization against seasonal influenza, which is not publicly covered, is remarkably low and is below 2.8% of the total population in 2016 (OECD, 2017).
From 1 January 2021, uninsured persons in Estonia will also be invited to all cancer screenings (breast, cervical and colorectal) funded by the Estonian Health Insurance Fund (EHIF). The groundbreaking decision was made after more than 10 years of discussions. Until now, access to cancer screenings and related treatment funded by EHIF for the uninsured population was not available. Limited access to the necessary prevention and diagnostic services has meant that uninsured people often ended up in the health care system too late, making it much more difficult and costly to treat them.
The change is necessary because early-stage screening of cancer is an important part of public health activities, the main aim of which is to reduce mortality at the population level. The amendment reduces inequalities in access to screening services and delays in necessary treatment.
Extension of cancer screening target groups to uninsured persons is estimated to cost EHIF an additional EUR 620,000 in 2021.
Seasonal influenza vaccination coverage rate has been low in Estonia. According to the Health Board, only 3.2% of the population was vaccinated against seasonal influenza in 2017. To increase the coverage rates, vaccination in pharmacies was allowed for the first time in October-November 2018. About 10% of all vaccinations took place in pharmacies, contributing to the increase of vaccination rate to 7.0%. In season 2019/2020 the vaccination rate against seasonal influenza increased further to 10.1% of the population, with a similar share in pharmacies. In addition, in the autumn of 2019, free influenza vaccination was provided for the first time in nursing homes, carried out by family doctors. Vaccination coverage in nursing homes was 67.4%; in the age group 65 and over it accounted for 13.6% of the total number vaccinated.
Vaccination in pharmacies continued in the autumn of 2020. Their marketing campaigns combined with the COVID-19 epidemic have significantly influenced people's attitudes towards vaccination. When in September 2020, about 153,000 doses of influenza vaccine arrived in Estonia (sufficient based on the experience of previous years), it ran out quickly. The activity of private firms has also increased drastically, who have ordered influenza vaccination in the workplace. By mid-October 2020, the flu vaccine ran out virtually everywhere. As a result, family doctors complained that they cannot get the necessary amounts of vaccine and risk groups may remain unvaccinated. As a solution it has been suggested that family doctors should pre-order necessary vaccination doses already early at the beginning of year for the following season or that influenza vaccination to be included in the national vaccination programme to assure vaccination of risk groups.
A recently published audit by the National Audit Office (NAO) found that the Veterinary and Food Board and the Ministry of Rural Affairs should provide better information about the risks related to pesticide residues on fruits and vegetables. Currently the information collected about food pollution is based on a small number of laboratory analyses that does not allow for accurate generalizations, which may misinform the population. Moreover, the information collected overemphasizes local food, which is usually cleaner than imported food, but the latter forms the majority of the fresh fruit and vegetables in people’s shopping baskets. The NAO also found that more efficient use of existing resources could considerably improve information analysis and presentations to the population.
Source: Summary in English available https://www.riigikontroll.ee/Suhtedavalikkusega/Pressiteated/tabid/168/557GetPage/1/557Year/-1/ItemId/1065/amid/557/language/et-EE/Default.aspx