Srdan Tatomir
OECD Economic Surveys: Estonia 2024
Abstract
Estonia has made significant progress in improving the health of its citizens, but life expectancy remains below most OECD countries. Inequalities persist with worse health outcomes among older men and low-income groups while access to healthcare varies across regions. To achieve the better health outcomes outlined in its national strategy, Estonia needs to address several key challenges. Insurance coverage should be extended towards a more universal system and out-of-pocket expenses reduced in a targeted way. The public health insurance system will need additional financing from 2025 to ensure sustainability. Funding should be increased further over the medium term to meet the increase in healthcare demand due to an ageing population, but this needs to be matched by improvements in efficiency. Widespread shortages of healthcare staff pose a significant challenge to delivering healthcare services. Better pay, working conditions and training can attract more nurses and doctors to work in the system. Better treatment and more prevention, which is highly cost-effective, can reduce inequality and improve the health of Estonia’s people.
Estonia has made significant progress in improving health outcomes over the past two decades. Life expectancy at birth rose by nearly eight years between 2000 and 2019, the largest increase in the OECD, to 79.0 years (Figure 5.1). This was driven by large declines in mortality from cardiovascular disease, cancer and injuries. However, life expectancy fell in 2021 due to COVID-19. It partly recovered to 78.1 in 2022 and should recover further. For men, life expectancy at birth was 73.6 years, while for women it was higher at 82.3 years (Statistics Estonia, 2023). Although life expectancy in Estonia is higher than in neighbouring Baltic countries, it remains below most European and OECD countries.
Source: OECD Health at a Glance 2023.
While Estonians have been living longer, they are not necessarily spending those additional years in good health. Healthy life years at birth, defined as the number of years spent free of long-term activity limitations or disabilities, were 57.9 years for men and 60.6 for women in 2022 (Statistics Estonia, 2024). Despite having increased over the past two decades, healthy life years at age 65 are lower in Estonia than in most OECD countries, particularly for men (Figure 5.2).The share of adults aged 65 and over who report their health to be fair, poor or very poor is the fourth highest in the OECD (OECD, 2023a). 8% of the population reported unmet health needs in 2021, the highest in the OECD. This is predominantly driven by high waiting times for specialist doctors, where there are acute shortages.
Healthy life-years at age 65, by gender, 2021 (or nearest year)
Note: Data comparability is limited because of cultural factors and different formulations of question in EU-SILC. Data for Iceland and the United Kingdom is for 2018 Data for Norway is for 2020. Based on Eurostat data.
Source: OECD Health at a Glance 2023.
Almost half of all deaths are due to circulatory system disease, such as ischaemic heart diseases, hypertension and stroke. These diseases were 70% more prevalent than the OECD average (Figure 5.3). Cancer contributes to around a fifth of all deaths, and the cancer mortality rate is 13% higher than the OECD average. Treatable mortality, deaths that could be avoided through earlier detection and treatment, are relatively high for circulatory diseases. Moreover, a third of all deaths could be prevented through better public health programmes that address behavioural risk factors, such as obesity and overall alcohol consumption, both of which are prevalent in Estonia (OECD, 2023b).
Death rates per 100 000 inhabitants (age-standardised), 2021 or latest available
Note: 1. Most recent data point corresponds to 2016-2019. External causes of death include accidents, suicides, homicides, and other causes.
Source: OECD Health at a Glance 2023.
Estonia’s health system fared better than those other OECD countries during the COVID-19 pandemic, although the pandemic impacted the health of the population significantly. The highly digitalised healthcare system supported the provision of healthcare through the pandemic with a third of medical consultations occurring remotely during 2020-21. Overall, hospital bed capacity is relatively high by international standards and was sufficient to manage COVID-19 patients as there was no shortage of beds, although bed occupancy was at its maximum during the peak in October and November 2021 (Health Board, 2023). Nevertheless, workloads for doctors and nurses during the pandemic were intense and this led to a higher rate of quitting in subsequent years. Mortality rates rose in 2021-22 partly due to COVID-19 deaths, but also due to other reasons such as an increase in alcohol-related deaths during lockdown. Mental health problems increased and have remained elevated (OECD, 2023a). The impact of the pandemic on waiting times was less pronounced than in other EU countries (OECD, 2023b).
Inequalities in health outcomes remain substantial and are wider than in most OECD countries. Many of the poor health outcomes are more prevalent among men: life expectancy at birth for Estonian women is broadly the same as the OECD average, but it is significantly lower for men (OECD, 2023a). Estonia has the third largest gender gap in life expectancy in the EU after Lithuania and Latvia. Socioeconomic status strongly influences health outcomes with people on lower income much less likely to report being in good health than those earning a higher income (Figure 5.4). These differences in health outcomes by income are among the largest in the EU. Furthermore, there are significant regional health inequalities. For example, there is a 14-year gap in life expectancy between regions (NIHD, 2021).
Share of population aged 15 years and over with good/very good health, 2022 or latest available
Notes: 1. Results for these countries are not directly comparable with those for other countries owing to methodological differences in the survey questionnaire resulting in a bias towards a more positive self-assessment of health. 2. Most recent data point corresponds to 2017.
Source: OECD Health at a Glance 2023 (EU-SILC for EU countries).
Estonia’s National Health Plan 2020-30 aims to improve health outcomes and reduce inequalities by 2030. It aims raise life expectancy at birth to 78 years for men and 84 years for women and increase the number of healthy life years at birth to 62 years for men and 63 years for women by 2030. Furthermore, Estonia aims to reduce health inequalities by improving the life expectancies of those with low education and low income, as well as narrowing the regional variation across the country (MoSA, 2023a). Better health should lead to higher well-being, as well as a healthier and more productive workforce, contributing to higher incomes and stronger public finances.
Estonia’s health care system is built around public health insurance with wide coverage across the population that funds primary care, hospital care and long-term care (see Box 5.1 for an overview). Healthcare expenditure has increased over the past two decades, but overall healthcare spending remains relatively low as a share of GDP. Total healthcare spending increased from 5% of GDP in 2005 to 6.8% in 2019, having briefly risen to 7.5% during the pandemic. It represents a significant share of the government’s budget, but the overall level of healthcare spending is well below the OECD average, which is close to 10% of GDP (Figure 5.5). Almost three quarters of health expenditure is covered by the government, mostly through the public insurance scheme, and the range of healthcare benefits is broad (OECD, 2023a). Hospital care is mainly covered by public insurance. While patients do not have to pay to see their family doctors, some degree of co-payment is required for specialist outpatient medical care services, such as laboratory tests. Co-payment is much larger for medicines and the majority of dental care is not covered by public insurance. Public spending on healthcare also includes funding long-term care and sick leave.
Healthcare expenditure as a share of GDP
Source: OECD Health at a Glance 2023.
Healthcare policy is legislated by the Parliament of Estonia which provides oversight of the system, particularly through the Social Affairs Committee. The government plays the executive role by planning and regulating the healthcare sector through the Ministry of Social Affairs and its subordinate agencies, that develop and implement overall health policy and supervise health service quality and access.
There are a few key agencies that support the Ministry. The Health Board licenses healthcare providers and registers healthcare professionals, supervises the safety of medical devices, and ensures the health system is prepared for emergencies. It monitors communicable diseases, provides epidemiological services and runs vaccination programmes. It enforces standards by monitoring compliance and healthcare quality. The State Agency of Medicines is responsible for the marketing authorisation and quality control of pharmaceuticals and promotes rational use of medicines. The Health and Welfare Information Systems Centre manages the e-health system, which is an information-exchange platform that connects all providers and allows data exchange between various databases. The National Institute for Health and Development (NIHD) is a research and development agency. NIHD conducts applied research, public health monitoring and evaluation, produces and disseminates official health statistics and maintains national medical registries. This helps inform national health strategies and policies. It also promotes health by marketing and supporting public health activities. Moreover, it trains and builds capacity in public health, management and social care.
The Estonian Health Insurance Fund (EHIF) is central to managing the public financing of healthcare. It is governed by a 6-member supervisory board consisting of representatives from state, employer and insured individuals’ organisations. To ensure political accountability, it is chaired by the Minister of Health while the Ministry of Finance is also represented. EHIF defines the benefits package and price list for health services, pharmaceutical and medical products. It sets delivery and quality standards, contracts out healthcare services, and finances healthcare services consistent with national health strategy and policy.
Primary care is a key pillar of the healthcare system (Figure 5.11). Family doctors are the first point of contact. They mostly work in independent practices, although around 40% are part of a primary health centre. They are required to work with at least one family nurse and are expected to take care of 1200-2000 patients. The Health Board determines a family doctor’s geographical service area, while the EHIF sets a minimum level of required service provision. Patients are free to choose their doctors. Family doctors exercise a partial gatekeeping function and control most access to specialist care. The Family Doctor Hotline service offers around-the-clock access to primary care.
Specialised medical care is provided by a network of hospitals. Hospitals are publicly owned and widely spread around the country and 94% of the population is within a 30-minute drive of a hospital. Regional hospitals offer a full range of services, while central hospitals do not offer certain surgery and oncology treatment. General and local hospitals provide 24/7 emergency care and fewer services. For emergency medical care, the Estonian Rescue Board operates a call centre, while ambulatory care is provided by hospitals and, to a lesser extent, by specialised private companies.
Nursing care is available in both hospitals and care institutions, as well as at home. Patients that need help and treatment following a trauma, serious illness or worsening chronic conditions can be admitted to inpatient care in hospitals. Nursing homes provide more constant health monitoring and care. For patients without the need for constant medical care but with reduced mobility, home nursing is available through regular visits by nurses. In all cases, a doctor decides whether a patient needs nursing care and refers them to the service.
Source: OECD/EO (2023b), Riigikontroll (2022), Tervisekassa, (2023a), Kasekamp et al (2023).
Ensuring an adequately funded healthcare system
The public health insurance system is largely funded on a pay-as-you-go basis. The revenues are raised through earmarked social contributions and government transfers to cover retirees. In 2022, EUR 1.6 billion or around 80% of total revenue was funded by social contributions paid by employees and the self-employed. Direct government transfers for pensioners, introduced in 2017, contributed another EUR 220 million or around 10%. Additional funds, amounting to around 6% of EHIF revenues in 2022, have been transferred from the state budget since 2021 in order to cover healthcare costs and ensure the availability of health services during the COVID-19 pandemic. However, these supplemental funds are set to end in 2025.
According to the Ministry of Finance, public health insurance spending will exceed revenues from 2025 onwards when the additional funds expire, potentially resulting in healthcare rationing as the Estonian Health Insurance Fund (EHIF) is legally not allowed to go into deficit. At the same time, demand for healthcare is expected to continue a trend increase in the years ahead, partly driven by population ageing, while revenues are expected to rise at a lower rate in line with income growth. When the additional funds expire, the deficit in 2025 would amount to EUR 161.5 million or 0.6% of GDP, rising to 1.4% of GDP in 2040. Assuming the additional funds are extended beyond 2025, the fund would be close to balance in 2025 but the deficit would still rise to around 1% of GDP in 2040 (Figure 5.6).
Source: Ministry of Finance and OECD calculations.
Given these funding pressures, Estonia needs to broaden and diversify the revenue base of the health insurance fund to ensure long-term viability while continuing to meet the population’s needs and providing comprehensive insurance. The additional funding introduced in 2021 should be maintained beyond 2025, which would retain the greater role of funding from general taxation. Further increases to cover rising funding needs should be tied to specific reforms to ensure increased spending is efficient. Additional funding needs should either be met through raising social contributions, which are already relatively high at 11.4% of GDP, or through general taxation. Raising additional revenues through general taxation is likely to be more efficient and less reliant on labour taxes, while earmarking funds through social contributions may help to link the spending and revenue from a political economy perspective. One option would to be require better-off pensioners to pay social health contributions and contribute towards the financing of the system. Pensioners pay health contributions, albeit at a lower rate in many OECD countries, such as in France or the Netherlands. With many pensioners in poverty or on low incomes, this approach needs to be targeted at pensioners with high incomes. Other options to raise additional funding by increasing the role of private provision would be difficult to implement in the Estonian context. The public insurance system works well, while the market would likely be too small for efficient private insurance (Habicht et al, 2018). Out-of-pocket payments are relatively high and cannot easily be raised.
Capital expenditure in the healthcare system partly relies on external funding. Estonia spent 0.5% of GDP on investment in healthcare in 2022, slightly above the OECD average (OECD, 2023a). Since 2004, it has modernised its healthcare infrastructure by building new, and renovating existing nursing care facilities and hospitals, and upgrading primary care centres. However, some infrastructure funding has come from EU structural funds. Over 2014-2020, the EU contributed EUR 132 million of EU funding to healthcare infrastructure in Estonia, accounting for around 16% of all health infrastructure spending. Estonia initially requested EUR 326 million for healthcare over 2021-2027 as part of the EU Recovery and Resilience Plan, but this has been reduced in the revised plan. In addition, as Estonia’s GDP grows, EU contributions towards healthcare infrastructure will decline.
Improving health insurance for all
The health insurance system has broad coverage of the population, but there are gaps that contribute to health inequalities that could be addressed at a reasonable cost. Health insurance coverage is not universal but 96% of the population was covered in 2022 (Figure 5.7). Almost half of the uninsured are estimated to work in Finland. Nonetheless, more than 10% of Estonia’s population experiences a temporary loss of health insurance during any given year. People in part-time, unstable or informal employment are more likely to be uninsured because most eligibility criteria are related to employment. Uninsured people are likely to be working-age, male, non-Estonian speaking and less educated (Habicht et al, 2018). They have limited access to public healthcare. Nevertheless, the uninsured generate healthcare costs that are one third higher than for insured people due to higher use of emergency care (Riigikontroll, 2018). Universal healthcare coverage should be gradually extended to all people permanently residing in Estonia in line with the norm in most other OECD countries. Cooperation with the Finnish tax authorities could help determine eligibility. While there is a concern that this could undermine incentives to work in the formal economy, Estonia has a robust system to ensure compliance and declaration of work. A gradual extension of coverage to different groups could help to manage any risks. Given most of the healthcare costs incurred by the uninsured are already reflected in total costs, it is estimated that it would only cost an estimated additional EUR 70 million or 0.2% of GDP to move to a universal system (Foresight Centre, 2021).
Share of total population, 2022
Note: Healthcare coverage is defined as a sum of total public coverage and primary private health coverage.
Source: OECD Health at a Glance 2023.
While co-payments are low across most of the system, total out-of-pocket payments are relatively high. Households paid for 23% of all healthcare costs out of their own pocket in 2022, accounting for 1.6% of GDP (Figure 5.8, Panel A). Most out-of-pocket spending went on dental care, which is mainly paid directly by households, and medicines where public insurance only covers 57% of the costs on average (OECD, 2023a). While these expenses are lower than in other Baltic countries, they are higher than in most OECD countries and twice the EU average. The WHO recommended limit for out-of-pocket spending is 20% of household income as higher payments can lead to financial difficulties. In 2019, 7.2% of all households experienced catastrophic out-of-pocket spending, where payments exceed 40% of household income (Figure 5.8, Panel B). Around two thirds of those households were among the poorest in Estonia. Medicines are the main driver of financial hardship, accounting for around half of catastrophic health spending (Vork et al, 2023).
Note: Catastrophic health spending is defined as out-of-pocket expenditure greater than 40% of household income.
Source: OECD Health at a Glance 2023; WHO Regional Office for Europe, 2023 (countries in Europe); European Observatory on Health Systems and Policies, 2021 (countries outside Europe).
Recent reforms targeted an expansion in pharmaceutical and dental care benefits to reduce out-of-pocket payments. In 2017, the dental care benefits for essential services were expanded to all insured adults with public insurance paying for half of the cost up to a maximum limit of EUR 40 per year (OECD/EO, 2023b). In 2024, this limit has increased to EUR 60 per year. For pharmaceutical benefits, reforms in 2018 lowered the eligibility threshold for annual co-payments from EUR 300 to EUR 100 and automated the administration of benefits through the centralised e-prescription system that automatically applies the benefit when patients purchase medicines. The reform improved financial protection as it increased uptake and lowered out-of-pocket payments (Habicht, Kasekamp and Webb, 2023). The share of households at risk of impoverishment fell to 4.4% in 2020, from 5.4% in 2015 (Vork et al, 2023). However, there is no cap on spending.
Given Estonia’s target level for out-of-pocket spending is 15%, there is still room to broaden healthcare services eligible for co-payments and improve targeting towards socially vulnerable groups. Estonia has higher annual dental care benefits of EUR 105 for socially vulnerable groups, such as pensioners and people with limited work capacity. This has been extended to those on subsistence benefits and the unemployed since 2022 and is the first benefit to be linked to household income (OECD/EO, 2023b). Some municipalities, such as Tallinn, support low-income households and older people but this is not widespread (Kasekamp et al, 2023). More targeting of dental and pharmaceutical benefits could further boost financial protection and efficiency. There remains scope to reduce co-payments for people on lower incomes and those with multiple chronic conditions. Introducing a cap on payments for low-income households would help to guard against catastrophic payments. Given Estonia’s digitalised health system and public administration, income-based targeting could be efficiently implemented.
Expanding long-term care
The demand for long-term care is rising as the population ages. Older Estonians are more likely to be in poorer health than their peers in most other OECD countries, particularly among lower income groups. Around 60% of people aged 65+ are limited in their daily activities. Many require social care to help with daily life and this is often provided by informal carers such as friends and family (OECD, 2023a). In addition, some require permanent healthcare. This can be provided in private homes or in more institutional settings such as a care home. While the number of places and workers in care homes is higher than the OECD average, demand continues to exceed supply and it is expected to rise significantly (OECD, 2021c). The share of the 65+ population is projected to rise from a fifth in 2019 to a third by 2050 while the population aged 80+ will almost double. Moreover, due to smaller and more geographically dispersed families, fewer elderly people will be able to rely on relatives than in the past (Foresight Centre, 2021).
Total long-term care spending on health and social care is relatively low. In Estonia, long-term care is financed by the public health insurance system (nursing care), state (special care services), local governments (social care), and through private spending. Around 0.7% of GDP is spent on overall long-term care (Figure 5.9). The public sector funds 0.4% of GDP, lower than the EU average, while 0.3% of GDP is financed privately (Foresight Centre, 2021). Total long-term care spending is substantially higher in some OECD countries with similar levels of income and shares of older people, such as Czechia, Slovenia and Lithuania, and ranges between 1.2% and 2%.
Reforms to long-term care benefits in 2022/23 boosted public funding for long-term care and have introduced more flexibility. Funding for long-term care was boosted by around EUR 40 million or 0.1% of GDP in 2023 and should rise to EUR 68.4 million by 2026. Municipalities are responsible for assessing a person’s needs and organising appropriate care. Previous support prioritised sending people to care homes, which is expensive, and provided little support to those in need of home care, which can be cheaper for those with low to moderate needs. Since 2022, municipalities are required to first offer home care services and only refer people to institutional care as a last resort. Combined with additional public funding introduced in 2023, this should make long-term care more cost-effective and is often also more in line with people’s preferences. This should allow informal caregivers, two thirds of whom do not work, to join the labour market. Estimates suggest this could add another 20,000 workers to the economy (MoSA, 2023c).
Measures to raise the supply of long-term care services should accompany the reforms. With more reliance on cost-effective home care services, additional care workers will be needed. However, care workers are low paid and endure poor working conditions (Kurmiste et al, 2022). As demand for formal care rises as a result of the reforms, market-based salaries for care workers should grow and encourage more people to work in long-term care. However, the government could further increase the attractiveness of the sector by regulating working conditions (Kurmiste et al, 2022). The recent reforms partly address this by setting maximum workloads per care worker. Moreover, the government could make more use of immigration to boost the number of care workers (see Section 5.4.4). Demand for institutionalised care will increase over time, requiring an additional supply of beds. To expand the number of long-term care homes the government could repurpose and convert smaller regional hospitals into additional care homes to support comparatively older populations in more rural areas.
Long-term care expenditure as a share of GDP, 2021 or latest available
1. Countries not reporting spending for LTC (social). In many countries this component is therefore missing from total LTC, but in some countries it is partly included under LTC (health). 2. Country not reporting spending for LTC (health).
Source: OECD Health at a Glance 2023.
There remains scope to improve the targeting of support for long-term care. The benefits reformed in 2022/23 are means tested with higher benefits provided to those on lower incomes. However, the benefits are capped and not closely linked to need. Previous OECD simulations suggested that the costs of long-term care homes for people with severe needs would exceed median incomes (OECD, 2023a). While this will apply to a minority of people, those affected might face health and poverty risks. To better address this, the size of the benefit should vary based on an assessment of different degrees of need as is done in Germany and Slovenia. The needs-based benefits could then be scaled by income while ensuring benefits are sufficiently generous to provide adequate access to long-term care and avoid poverty.
Total spending on long-term care should increase further to address rising demand. To maintain existing levels of care and meet increased demand due to population ageing, public spending on long-term care will need to rise to 0.6% of GDP by 2050 (European Commission, 2021). The risks are on the upside. For example, to the extent that costs converge to EU averages, this could rise to as much as 2.1% of GDP by 2050. Funding models for long-term care vary across OECD countries, but government support tends to be a key component (Box 5.2). In Estonia, sustainable and efficient long-term care should be centred around public support with an appropriate social safety net. This could be funded by a well-defined mixture of public and private provision. Private insurance markets may be difficult to operate, but different ways to manage the risks around long-term care could be explored. Since long-term care costs are uncertain, it may make sense to set aside funds for the future. In Germany, a share of social long-term care contributions is reserved to pre-fund and smooth future care costs.
Long-term care is provided by a diverse set of stakeholders such as nursing homes, healthcare institutions, and families. Home care tends to be more cost effective while institutionalised care, provided in a care home or hospital, tends to be expensive. The importance of each varies across OECD countries. Estonia spends a total 0.7% of GDP on long-term care, of which close to 70% is on nursing homes and just under 10% occurs in hospitals. Other OECD countries, such as Korea and Spain, spend around 1% of GDP on long-term care but provide more home care compared to Estonia (Figure 5.10). Care provided by households, that is, informal paid care plays a prominent role in Austria and Lithuania. However, in some countries such as Greece, Türkiye, Chile and Mexico, much of the care is provided by unpaid family members.
Long-term care spending by provider, 2021 (or nearest year)
Notes: 1. Countries not reporting social LTC. The category “Social providers” refers to providers where the primary focus is on help with IADL or other social care.
Source: OECD Health at a Glance 2023.
Most long-term care is supported through public funding and compulsory social insurance, although the share of public funding varies across countries. In Estonia, the share of public funding is on the lower side at under 60%. For example, public funding accounts for around 70% of total long-term care spending in Slovenia and Austria and around 90% in Denmark and the Netherlands. Spending on long-term care tends to be predominantly focused on health but some OECD countries also spend on social support such as personal care services that help with daily living activities.
Most OECD countries finance long-term care spending from a number of sources. Public funding relies mainly on long-term care insurance in a few countries such as Belgium, Germany, Japan, Korea, Luxembourg and the Netherlands. In Germany, a share of future long-term care costs is pre-funded from current contributions. Other OECD countries rely on taxes only or on a combination of social contributions and taxes. In Scandinavian countries, central government funds are distributed across municipalities based on income and needs. Private funding for long-term care mostly comes out-of-pocket. Private insurance is available in the United States and Japan, but it only covers a fraction of the costs. Reverse mortgages and home equity schemes exist in the United States, United Kingdom, France, New Zealand, Spain and Canada, but they are not used widely and are often concentrated in areas with high real estate prices.
Source: OECD (2020), OECD (2022b).
Outcomes and efficiency in Estonia’s healthcare system
Overall, Estonia’s healthcare system is well-designed and creates incentives to provide appropriate care in an efficient way, although there are some further improvements that could help to manage cost pressures. The delivery of healthcare is overseen and managed by the Ministry of Social Affairs (MoSA) and its various agencies (see Box 5.1). Policy is guided by the National Health Plan that integrates existing sectoral health plans, strategies and development plans. The Estonian Health Insurance Fund (EHIF) mainly finances healthcare services, which are organised into four categories: primary healthcare, emergency medical care, specialised medical care and nursing care. The provision of these services is decentralised among public and private providers (Habicht et al, 2018a).
The efficiency of the healthcare system has increased over time. Estonia has been centralising its healthcare management since the late 1990s. The Ministry of Social Affairs has assumed more planning responsibilities, while more administrative powers given to EHIF helped lower healthcare costs and boost analytical capacity. Estonia has increasingly focused on strengthening primary healthcare alongside specialist outpatient care, which plays an important role and has contributed to relatively low avoidable hospital admissions (Figure 5.11) (Habicht et al, 2018a). Further financial incentives have been put in place since 2017 to encourage the consolidation of individual practices into primary health care centres. Healthcare records and services have been largely digitalised which has reduced the administrative workload and costs. As a result, Estonia has managed to significantly raise life expectancy, while only increasing the share of health expenditure in GDP by 2 percentage points over the past two decades.
Health expenditure by type of service, 2021 or latest
Note: Countries are ranked by curative-rehabilitative care as a share of current expenditure on health.1. Refers to curative-rehabilitative care in inpatient and day care settings. 2. Refers to outpatient care, including specialist care, as well as home care and ancillary services.
Source: OECD Health at a Glance 2023.
While health outcomes are consistent with a comparatively low level of spending, other countries have managed to achieve better outcomes with a similar budget. This suggests that there may be further room for improvement in efficiency. A recent OECD study by Dutu and Sicari (2020) uses a non-parametric technique to estimate a frontier of countries that are best in maximising health outcomes based on the resources they spend. Although subject to caveats, this analysis suggests that Estonia, given its current spending, could potentially raise life expectancy by 4.5% relative to the best performing countries without increasing spending (Figure 5.12), although this may be difficult to achieve. Many of the recommended prevention and treatment policies discussed in Section 5.5 would boost life expectancy at small additional cost, leading to higher efficiency. There are other areas which could yield additional efficiency gains. The EHIF’s analysis suggests that efficiency savings up to 1% of total public health expenditure could be made through better use of technology, improved administration and enhanced financial incentives (Tervisekassa, 2023b).
Potential gains in life expectancy
Note: Efficiency is estimated using data envelopment analysis to explain healthcare outcomes, as proxied by life expectancy at birth, by inputs such as health expenditure and a composite indicator that captures effects of the socio-economic environment and life-style factors. The estimates refer to potential gains in output efficiency while keeping inputs constant.
Source: Dutu and Sicari (2020).
Increasing efficiency through financial incentives
Different elements of the healthcare financing system could be adjusted to improve incentives and boost efficiency in the context of funding pressures. The EHIF offers mostly in-kind benefits to patients by contracting services from private and public providers. As a single payer with the healthcare system, it has strong bargaining power and expertise that allows it to achieve lower costs and set differential prices for healthcare services to achieve national goals, such as improving health outcomes in specific areas, driving efficiency improvements and ensuring a broad geographical availability of healthcare across Estonia (see Box 5.3 for more details).
Funds from the Estonian Health Insurance Fund (EHIF) pay for the provision of medical services. The EHIF negotiates standard contract conditions with provider associations such as the Estonian Family Physicians Association, the Estonian Hospital Association and emergency care providers. This ensures contract terms are universal and apply to all providers. In addition, financial details are negotiated by each provider individually for one year. Service prices, the benefits package and payment methods are included and regulated in a single government-approved health service list.
In primary care, family doctors and nurses are paid through a combination of a basic allowance, capitation payments, fees for services and quality-related bonuses. The system is designed to incentivise doctors to take more responsibility for diagnostic services and treatment, to provide continuity of care and to compensate them for the financial risks of caring for older people and working in remote areas. For example, the quality bonus scheme pays doctors when they achieve targets in disease prevention, chronic disease management and additional professional competence areas. This is measured based on a selection of indicators agreed by EHIF and the Estonian Family Physicians Association.
Specialist care is remunerated at different levels through fees for services, per diem fees and diagnosis-related group payments. Diagnosis-related payments cover all inpatient care and outpatient care that involves surgeries. Per diem fees cover the costs of basic examination, diagnosis and treatment planning, nursing, meals, simple medical procedures, laboratory tests and pharmaceuticals. The EHIF also pays for amortisation costs while EU regional funds have supported healthcare infrastructure in general.
Source: Habicht et al (2018a).
Further development of primary health centres should be encouraged. Primary health centres are more efficient than individual practices due to lower administrative and management costs. They can also increase accessibility as they offer a range of additional services such as physiotherapy, midwifery, and home nursing. Financial incentives introduced in 2017 offered additional funding to incentivise family doctors to form health centres and 43% of all family doctors had joined by the end of 2022. However, health centres are not evenly distributed across Estonia. They are present in 35 municipalities, most of which only have one centre. The remaining 44 municipalities, many of which are rural, do not have any primary health centres (Riigikontroll, 2022). Financial incentives should be expanded for those regions, where feasible, to increase support for investments necessary in setting up a health centre and attracting staff to provide additional services (Habicht, Kasekamp, and Webb, 2023). Moreover, municipalities have the right to establish health centres, but have rarely used it (Habicht et al, 2018a). The Ministry of Social Affairs should provide advisory and technical support to those municipalities with few primary health centres in order to develop them.
Making more use of user charges could boost the efficient use of scarce resources. Primary care is free in order to maximise access to basic healthcare and to avoid unnecessary use of specialist and emergency care. Introducing a small user charge could reduce unnecessary visits. Specialist care, which requires a referral from a family doctor, is charged EUR 5 per visit. This was raised from EUR 3.20 in 2013 but has not been reviewed recently. Referrals should be conducted as e-consultations by default while user charges for specialists should be raised. In addition, requiring specialists to decide whether a referral is necessary could potentially free up scarce resources. Exemptions for those on low incomes and others in need will be necessary to preserve accessibility. Raising user charges could also increase revenues for the public health insurance fund but this is likely to be modest given the exemptions needed.
Increasing the role for performance payments could boost healthcare outcomes and lower costs. Estonia introduced quality bonuses in 2006, before many OECD countries, with the aim to increase the quality and effectiveness of preventive healthcare and improve chronic disease management. All family doctors now participate in the quality bonus scheme. This has improved health and lowered costs (Lai et al, 2015). However, the relative size of the bonus scheme could be increased to incentivise further efficiency gains. Estonia’s bonus scheme accounts for 3% of family doctor incomes, while such incentive payments in OECD countries typically range between 5% and 15%. In the United Kingdom, up to 10% of GP practice income comes from incentive payments in the quality and outcomes framework; in Türkiye, around 20% of primary care provider salaries comes from incentive payments. Furthermore, higher performance could better differentiated and rewarded more within the scheme (NHS England, 2018; Forde et al, 2018).
Greater use of outpatient care could lower healthcare costs. Advancements in surgical techniques and technology have widened the range of procedures that can be done within a day and would avoid overnight stays in hospitals. Day care is advanced in ophthalmology, where all cataract surgeries are completed on the day. However, the use of day care for other procedures varies. For example, only 37% of tonsillectomies are done within a day, less than in most other OECD countries (OECD, 2023a). The use of day care also varies widely between hospitals. There is room to further increase the use of day care in areas, such as varicose vein operations and several orthopaedic and gynaecological surgeries (Habicht et al, 2018a). The EHIF funds day care separately and could sharpen incentives to transfer surgeries from inpatient to day care settings to further lower costs.
Additional efficiency and cost savings could be achieved through consolidating the hospital network. Previous estimates suggested that the recommended number of hospitals was 13, but the number of hospitals in 2022 totalled 20. The optimal number of hospitals will depend on healthcare needs and geographical coverage, but the government’s goals are unclear as the hospital network development plan has not been updated since 2015. However, many hospitals across Estonia have reduced the number of specialised healthcare services, mainly due to a shortage of medical specialists (Riigikontroll, 2022). As workforce shortages will not be immediately resolved and a high volume of services is needed to achieve efficiency and maintain patient safety, a consolidation of the hospital network may be needed to ensure hospitals can offer a range of services while minimising their fixed costs. However, this should be balanced against the need for resilience as experience during the pandemic showed that some degree of spare capacity is essential for managing a surge in health demand during a crisis (OECD, 2023f). Supported by EU funds, the Ministry of Social Affairs has commissioned technical analysis of the hospital network and is moving towards developing a new hospital network development plan. This should be accelerated and accompanied with a concrete plan for consolidation if required.
Reducing pharmaceutical costs
Pharmaceutical prices are likely to be higher than needed given obstacles to competition, inefficient purchasing practices and low use of generic medicines. In 2022, Estonia spent EUR 359 million on medicines sold in pharmacies, 70% of which were composed of prescription medicines and the remainder were sold over the counter (Estonian Medicines Agency, 2023). On a purchasing power basis, pharmaceutical spending per capita is broadly similar to the OECD average but the share of generic medicines remains relatively low. In 2022, 16.7% of medicines sold by value were generic, while the volume of generic medicines made up 37% of the total. The use of generics is below the OECD average and significantly below neighbouring Latvia (Figure 5.13). The market share of generics is correlated with pharmacies’ profit margins which suggests that, despite regulatory pricing incentives, competition in the retail market could be higher (Holmas, Brekke and Straume, 2013). In addition, the wholesale market is dominated by a couple of large companies.
Share of generics in the total pharmaceutical market, 2021
Note: 1. Reimbursed pharmaceutical market refers to the sub-market in which a third-party payer reimburses medicines. 2. Community pharmacy market.
Source: OECD Health at a Glance 2023.
Estonia has implemented policies to reduce pharmaceutical costs and encourage competition with some success. A regressive cost-plus markup system, used to determine maximum prices for medicines, has been in place for around two decades. Mark-ups are highest for low priced medicines in order to make cheaper pharmaceuticals more profitable for wholesalers and retail pharmacies. A reference pricing system in Estonia uses prices from different manufacturers and a comparison with Latvia, Lithuania, and Slovakia is used to set reimbursable medicine prices. Doctors are required to prescribe pharmaceuticals by their International Non-proprietary Name (INN) as the default option, which is supported by the e‑prescription system, and pharmacies have to offer a range of medicines including the cheapest alternative. This has led to lower prices and an increase in the volume of generic medicines since 2010 (Habicht, 2018b; OECD, 2023a). However, reforms made in 2015 that prohibited wholesalers from owning retail pharmacies have not led to an increase in retail competition. This was partly due to franchise agreements between wholesalers and retailers that incentivise kickbacks and limit the pharmacies’ ability to work with competing wholesalers (Habicht, 2018b).
Easing restrictions on supply could lower pharmaceutical prices. Hospitals account for about a third of pharmaceutical consumption and each individual hospital is responsible for procuring medicines. This is done through direct purchases and tenders from wholesalers licensed in Estonia. However, the wholesale pharmaceutical market is concentrated with the largest two wholesalers accounting for 81% of the market share. To increase their bargaining power and reduce prices, hospitals should jointly purchase medicines. Furthermore, hospitals should also be granted the right to buy medicinal products in other EU Member States and directly from manufacturers if the medicine is cheaper and included in the EHIF benefits list (ECA, 2022). Moreover, building on the success of the Baltic Procurement Initiative for vaccines, Estonia should make more use of joint procurement with other Baltic countries for a wider range of pharmaceuticals (Vogler et al, 2021). This could further lower prices.
Competition among retail pharmacies should be increased and supervision in the pharmaceutical market strengthened. The indicator of product market regulation has not changed between 2019 and 2023, and suggests regulation in the retail pharmacy lags behind best practice. This is because existing rules prescribe limits on geographical density of pharmacies and restrict the sale of non-prescription medicines to pharmacies. Moreover, there are ownership restrictions. A new law introduced in 2015 requires retail pharmacies to be majority owned by pharmacists, rather than owned by wholesalers, and limits ownership to 4 pharmacies. Easing product market regulations would boost competition and lower prices. Removing geographical limits could increase the number of pharmacies. Ownership restrictions, particularly given the declining number of pharmacists, could restrict competition and should be eased. In addition, there are concerns about exclusive franchise agreements limiting competition between wholesalers and non-transparent medicine pricing leading to higher prices (ECA, 2020a, 2020b). To increase competition, Estonia should conduct an in-depth audit of the pharmaceutical market to reduce barriers to competition.
Upgrading digital healthcare through better data use
Digitalising healthcare further could help to improve efficiency. Estonia is highly advanced in digitalising public services. It provides many healthcare services and tools online. All Estonians have an electronic health record (Figure 5.14). The use of online consultations is high, and all prescriptions are electronic. A secure data exchange system, X-road, allows eServices between the public and private sectors to be connected which, for example, supports eAmbulance services by providing direct access to health records in an emergency. Additionally, the EHIF has used electronic billing data since the late 1990s, ahead of many other EU Member States (OECD, 2022c).
Data can be used better to monitor healthcare services and improve health outcomes. Estonia performs well in primary data use. There is a significant amount of information collected and all databases are structured to support the functions of each healthcare institution. This has facilitated digitalisation of healthcare services. Despite the broad availability of healthcare data, health statistics are not designated as official statistics and they are interspersed between multiple institutions. This makes linking datasets difficult and time consuming, which has hampered wider secondary use of data for healthcare performance monitoring, analysis and research. For example, Estonia uses health data for monitoring public health and patient safety and it is starting to use it for monitoring health system performance such as waiting times (Oderkirk et al, 2021). Effective use of data and digital technologies can yield large economic benefits with estimated savings of 8% across OECD countries, on average, of total health expenditure (OECD, 2019a). It can also boost resilience as the pandemic has shown that more digitalised health systems can cope better in crises (OECD, 2023f).
Percentage of primary care physician offices and acute care hospitals using electronic medical records, 2021
Source: OECD Survey of Electronic Health Record System Development and Use, 2021.
Addressing challenges with data collection and quality is necessary to further leverage healthcare data. There are concerns with manual data inputs as the quality of electronic health records does not meet the requirements for compiling reliable health statistics. There is a need for more automated quality controls, but current healthcare software design does not sufficiently consider quality data entry and processing (Kirpu & Eigo, 2018; Liivlaid, 2019; Maasoo, 2022). The coverage of collected data varies by dataset and non-standardised definitions reduce data comparability. Some reports from healthcare providers are provided in aggregated format, which makes it difficult to verify and impossible to link to other datasets (OECD, 2023c). Estonia should invest more in improving the quality of administrative healthcare data collection.
Further obstacles need to be removed to improve database linking and interoperability. Estonia collects almost all key national health datasets recommended by the OECD except for diabetes data. Many datasets have the same unique patient ID that allows for linking. However, just a quarter are inter-linked, which is below most OECD countries (Figure 5.15). Currently, only mortality data and certain disease registry data, such as cancer and tuberculosis, are linked on a regular basis (OECD, 2023c). Some data collected by NIHD is reported in aggregated format and should be replaced with statistics underpinned by individual records. Furthermore, it is difficult to link health and tax data, which is important for improving the targeting of health benefits. Estonia is implementing the latest global standards to improve interoperability. However, the key obstacle to linking databases is that health data are not classified as official statistics. This makes accessing each database for regular statistical purposes a complicated process. While data access needs to be balanced with data privacy and security concerns, countries such as Denmark, Canada and Finland have successfully managed to link their healthcare data. Estonia should find a solution to add health statistics to the official statistical programme in order to allow for quicker and wider access while ensuring data remains secure and private.
2019-20
Note: Includes 10 national datasets of hospital in-patients, mental hospital in-patients, emergency care, primary care, prescription medicines and long-term care; national cancer, cardiovascular disease, diabetes registries; and national mortality data. Time lapse of 1 week or less between when a data record is created and when it is included in the dataset used for analysis. * refers to Scotland.
Source: OECD Survey of Health Data and Governance, 2019-20; Oderkirk (2021), “Survey Results: National Health Data Infrastructure and Governance”, https://doi.org/10.1787/55d24b5d-en.
Efforts to improve data collection and linking should be centralised. Data ownership and use is fragmented across several healthcare institutions that work separately and have little interaction with each other on data issues (OECD, 2023c). Many of the barriers to better healthcare data use are common and central coordination could benefit from economies of scope in improving data quality, implementing common standards and definitions, leading in linking datasets and enabling open and secure access to healthcare data. The Ministry of Social Affairs, alongside stakeholders across the health system, is currently undertaking a comprehensive health system performance assessment (HSPA), which is expected to help identify how to practically improve governance structures, policies, and processes which would ensure the consistent and systematic generation of health-related indicators. Following this assessment and the upcoming European Health Data Space framework, Estonia should adopt a clear structure for the governance of its health data and develop a detailed action plan on how to centralise and improve data collection and availability.
Estonia is facing a shortage of doctors, nurses and other health professionals
A key challenge to delivering quality healthcare and the government’s objectives is ensuring a sufficient number of health workers. Adequate healthcare staff levels are also key to a resilient healthcare system since workloads can surge during a crisis as the pandemic has shown (OECD, 2023f). Estonia has experienced a persistent shortage of health workers as a result of an ageing workforce, migration and an insufficient number of medical and nursing graduates. This has led to long waiting times and lower access to healthcare. There is a nationwide shortage of nurses as the Estonian Nurse Association reported 1000 vacancies in 2023, accounting for 12% of all nursing jobs across the country (ENA, 2023). The average age of nurses has risen to 45 years, and it is higher in areas such as rehabilitation, schools and long-term care. Similarly, the average age of doctors is 51 and almost half of all doctors are aged 55 or older, the fourth highest share in the OECD. In 2021, there were vacancies for at least 52 family doctors (about 5% of all practicing family doctors). To compensate for the shortage of staff, doctors worked overtime hours amounting to an additional 116 full-time doctors (around 3% of the total medical workforce). There is an acute shortage of family doctors, especially outside the biggest cities and shortages of medical staff in emergency care, psychiatry and psychology (Riigikontroll, 2022).
The number of health workers relative to the population is low compared to other OECD countries. The ratio of nurses relative to the population has been broadly the same over the past two decades, while it has risen in most OECD countries (OECD, 2023a). The ratio of doctors in Estonia has increased although this increase has been among the lowest in the OECD. In 2021, there were 6.4 nurses per 1000 people, well below most OECD and EU countries. The ratio of doctors was 3.4 per 1000 people, slightly below the OECD average and lower than in most EU countries (Figure 5.16). To reach EU average levels, Estonia would need to boost the number of doctors by 14% or 650 doctors and increase the number of nurses by 31% or 2600 nurses.
Notes: The OECD average is unweighted.
Source: OECD Health at a Glance 2023.
In the context of a declining workforce and a tight labour market, increasing the numbers of nurses and doctors will be a significant challenge. As the demand for healthcare grows more healthcare staff will be needed, but the ageing workforce is likely to worsen the shortage further (Riigikontroll, 2022). Addressing this will require a sustained multi-pronged policy effort. While pay is more of an issue for nurses, retaining both nurses and doctors will be increasingly important and improving working conditions can play a key role. More doctors and nurses will need to be trained. Estonia could also make more use of immigration to boost its medical workforce.
Raising pay, increasing retention and improving working conditions
Boosting pay could increase the supply of healthcare staff. Higher pay levels can attract new nurses while, at the same time, discourage existing nurses from leaving. In Estonia, nurses’ wages are above the average wage, but slightly lower than the OECD average (Figure 5.17, A). The latest two-year collective agreement in Estonia increased salaries in healthcare by 20% in April 2023 and will raise them by a further 10% in 2024. This should bring the ratio of nursing salaries broadly in line with the OECD average. However, given freedom of movement within the EU, remuneration in other countries matters. In neighbouring Finland nurses can earn more than a quarter more than in Estonia adjusted for differences in purchasing power and significantly more in cash terms (Figure 5.17, B). This strengthens the case to ensure that nurses’ pay is sufficient, including for younger nurses who might be more inclined to emigrate. All general practitioners in Estonia are private and those who were self-employed were paid 3.1 times the average wage in 2021, which is among the highest ratios in the OECD (Figure 5.18, A). However, remuneration for salaried general practitioners and specialist doctors could be improved. Specialists, who mostly work in hospitals, were paid 2.3 times the average wage (Figure 5.18, B). This ratio is higher in Finland and in most other OECD countries.
Remuneration, 2021 or nearest year
Note: Panel A: 1. Data refer to registered (“professional”) nurses only in the United States, Canada, Ireland and Chile (resulting in an over-estimation). 2. The data for New Zealand and Switzerland include “associate professional” nurses, who have lower qualifications and revenues. Panel B: 1. The data also include “associate professional” nurses who have lower qualifications and revenues.
Source: OECD Health at a Glance 2023.
Remuneration relative to the average national wage, 2021 or latest available
Note: 1. Includes physicians in training (resulting in an underestimation). 2. Includes practice expenses (resulting in an overestimation).
Source: OECD Health at a Glance 2023.
Better working conditions can make nursing more attractive. Heavy workloads contribute to higher staff turnover and make the profession less attractive to prospective entrants. The workload has increased in Estonia as the population has aged (Ernits et al, 2019). The use of overtime hours to partly address the shortage of nurses has risen by 50% since 2016. During the pandemic, the need for nurses rose sharply as in many OECD countries. This was particularly acute among nurses working in emergency services and intensive care. The average number of patients per nurse grew to 20, up from 12-14 patients before the pandemic (Riigikontroll, 2022). Workload pressures continued in 2022 as the amount of overtime hours was equivalent to hiring an additional 3% full-time nurses. The situation is similar for doctors where overtime hours in 2022 also accounted for around 3% of the workforce. Heavier workloads can also worsen healthcare quality. For example, an additional patient per nurse increases the likelihood of inpatient death by 7% within 30 days (Lancet, 2021).
Setting personnel standards for the whole healthcare sector would improve general working conditions. More explicit guidance on working practices, such as setting limits on the number of patient consultations in a given time period and overtime hours, should be provided. The Occupational Health and Safety Act regulates the physical safety of workers but regulations that prescribe quality standards and working hours in healthcare are largely missing. In 2012, the collective agreements acknowledged the need to develop personnel standards, but these have only been implemented in intensive care and inpatient nursing care. They are absent in other specialties, leading some hospitals to increase workloads (Riigikontroll, 2022).
Nurses no longer working in healthcare could help to fill current vacancies. According to the Healthcare Providers’ Information System, a little more than half of qualified nurses worked in healthcare in 2022. The Ministry of Social Affairs has recognised this and started return programmes for nurses in 2015. Six-month courses taught at Tallinn Health Care College, funded by the Ministry, help participants refresh their knowledge and skills. Around 20-30 nurses complete the course each year and, in the past, 85% have returned to work as nurses (ERR, 2019). Given their success and as part of wider efforts to increase the nursing workforce, these programmes should be expanded to attract more former nurses back into healthcare.
The shortage of family doctors is particularly acute and will be exacerbated by ageing as almost half of all doctors were 55 years of age or older in 2021 (Figure 5.19). More family doctors are retiring than new ones are joining (Riigikontroll, 2022). The inflow of Ukrainian refugees has increased the demand for healthcare further. Around 5.5% of the population is covered by substitute doctors who, in addition to their own patients, temporarily look after those without an assigned doctor. But substitute doctors have their own patients, and a quarter are approaching retirement age. It is increasingly difficult to replace family doctors and some patients have been covered by a temporary doctor for many years. Elderly populations in rural regions are expected to increase much more than in urban regions, adding pressure on the relative shortfall of family doctors in rural areas (OECD, 2022a). Persistent shortages of family doctors could lead to worsening healthcare access and decrease the efficiency of healthcare as more patients rely on emergency services (Riigikontroll, 2022).
Share of doctors aged 55 and older, 2021
Source OECD Health at a Glance 2023.
Since many doctors are close to or over retirement age, policies that incentivise postponing retirement could boost the number of doctors. In Denmark’s Northern Jutland, GPs received additional payments between the ages of 62 and 65, while in the German state of Thuringia, GPs aged 65 and above are eligible for additional pay in underserved rural areas (OECD, 2016). Nonetheless, non-financial incentives can be equally as important. Studies suggest that reducing working hours and workload intensity can encourage doctors to practice longer (Silver et al, 2016; Cleland et al, 2022). But the EHIF rules on opening hours and patient lists for practices run by family doctors make it difficult for smaller practices to flexibly adjust hours. These rules should be relaxed to facilitate the retention of older doctors.
Hiring more administrative staff could lighten nurses’ workloads. There is a shortage of administrative staff in the health system and this puts an additional burden on nursing staff (NIHD, 2023). Administrative staff do not necessarily require clinical qualifications and can be more effective than nurses. Such task shifting could then provide nurses with more time to provide healthcare to patients.
Training more nurses and doctors
Overall, the rate of training remains too low given the need to improve healthcare, persistent shortages and an ageing workforce; and needs to be increased further. Around 350-400 nurses have been graduating annually in recent years, but the rate of training has decreased overall since 2012. Estonia remains below OECD and EU average levels of training of nurses (Figure 5.20, A). However, the number of training places has been raised to 700 in 2023-24, just reaching the annual requirement of 700-800 graduates that was the estimated number of graduates required each year from 2014 in order to achieve OECD and EU averages by 2032. More will be needed to make up for previous shortfalls. In addition, there are 170 Ukrainian refugee nurses and 22 are studying towards Estonian qualifications (ERR, 2023a).
Training rates per 100,000 inhabitants, 2021
Note: A large number of medical graduates are international students in some countries (e.g. Ireland, the Slovak Republic, Czechia and Hungary). Data excludes international students, resulting in an under-estimation (about 15% of graduates in Israel and 5% in New Zealand were international students in 2021).
Source: OECD Health at a Glance 2023.
More doctors need to be trained as well. All doctors are trained at the University of Tartu, where it takes 6 years of studies to qualify as a doctor and be able to practise medicine. Afterwards, doctors can continue with postgraduate specialist medical training in a residency at a medical institution to qualify as a specialist doctor. Doctors of family medicine are defined as specialists in Estonia as in most other countries. The previous Survey recommended increasing medical admission quotas (OECD, 2022d). While the number of admission places almost doubled between 2000 and 2022, it has remained broadly unchanged since 2021. Training rates continue to lag behind most OECD and EU countries (Figure 5.20, B). The level of admissions is still below that needed to cover future needs, estimated by the Ministry of Social Affairs to be 200 admissions per year (Habicht et al, 2018a). For postgraduate specialist training, the number of residency places grew by 15% between 2019 and 2022 (Riigikontroll, 2022). Residencies for family medicine have been boosted from 35 to 40 places but this continues to be below 50, which is the estimated level necessary to overcome the shortage of family doctors (De Maeseneer, 2016).
The additional supply of doctors should be balanced across different specialisations. Interest in specialisations is not perfectly aligned with existing shortages. For example, applications for emergency medicine amount to only 25-30% of available residency places because of high work intensity, difficult working conditions, and limited development prospects (Riigikontroll, 2022). Resident doctors have fixed term employment contracts with teaching hospitals and this education is funded by the Ministry of Social Affairs. To encourage more doctors to specialise in disciplines in high demand, residency salaries should be increased for specialisations where the need is higher and lowered where there is plenty of interest. A similar system has been effectively implemented in Lithuania, where higher education grants vary depending on future shortages in different disciplines (Eurydice, 2023).
Trained nurses should be based widely across regions to ensure adequate access to and quality of healthcare. Today, nurses are trained in health colleges in Tallinn and Tartu, the two biggest cities, and training lasts 3.5 years. Tallinn Health College already has cooperation agreements with Parnu hospital while Tartu Health College has established a new agreement with Narva hospital to provide practical nursing training (ERR, 2023b). This progress should be continued and, where feasible, the authorities could develop additional teaching centres in different regions to boost training and attract local workers.
A broad geographical spread of doctors is needed as well. However, most resident doctors only want to practice in Tallinn and Tartu. Retiring family doctors in rural areas are increasingly not replaced (Riigikontroll, 2022). The Ministry of Social Affairs already differentiates salaries based on regional demand as attracting doctors at an earlier age would increase the likelihood that they stay in the local area. While financial incentives may compensate for the disadvantage of locating in less attractive regions, they are not a ‘game changer’ for location choice (OECD, 2016). The Ministry of Social Affairs should invest in modern equipment and facilities in general, and invest in county and local hospitals as this can boost the attractiveness of facilities located outside larger cities. The authorities could admit more students from rural areas by offering scholarships, for example, as this can also increase regional mobility (MacQueen et al, 2017).
Making more use of immigration
Immigration could help alleviate labour shortages in healthcare. Foreign-trained nurses only account for 0.2% of nurses in Estonia, one of the lowest shares among OECD countries (Figure 5.21, A). More foreign nurses should be attracted to help address shortages in the short term and mitigate the loss of nursing staff to other countries. Increasing the number of foreign-trained doctors can also fill vacancies. Only 4% of doctors are foreign-trained in Estonia, well below the OECD average (Figure 5.21, B). They mostly come from Russia and Ukraine while some are from Finland.
There is significant potential to attract more foreign doctors and nurses as the barriers to entry into the medical profession are high. Non-EU qualifications are not easily recognised. The government is developing legislation for recognising foreign non-EU medical qualifications. This should be accelerated while ensuring foreign qualifications meet minimum quality criteria. Estonia currently requires practicing healthcare professionals to possess a high-level of Estonian language knowledge. While it is important for people to be able to access medical care in Estonian, there is scope to relax this requirement initially and allow for greater flexibility so that foreign nurses and doctors can start practising earlier, while further improving their knowledge of Estonian and without compromising patient care as some other countries have done. More use of translation services, as practiced in Sweden, could be relied on where necessary to ease communication. Furthermore, Estonia could expand the number of foreign medical students trained in the country. The University of Tartu offers a medical study programme in English for fee-paying students. The programme teaches Estonian language and allows graduates to work in local hospitals and offers pathways to specialise through residency programmes.
Bilateral migration programmes could boost the supply of foreign medical professionals. Several OECD countries have set up mutually beneficial migration programmes for healthcare professionals in order to facilitate migration between countries. The United Kingdom has signed memoranda of understanding with India, Kenya, Malaysia, Nepal, the Philippines and Sri Lanka to develop migration pathways that benefit the UK and the sending countries (Department of Health and Social Care, 2023). Germany established a similar bilateral agreement with Vietnam in 2012 to train and recruit geriatric nurses, while also providing German language training (OECD, 2016). Estonia could benefit from a similar bilateral programme to facilitate migration from non-EU countries. It should launch campaigns in other countries to attract more nurses and doctors while respecting the WHO’s global code of practice on the international recruitment of health personnel.
2021 or latest year available
Source: OECD Health at a Glance 2023.
Enhancing data collection and workforce planning
Better data collection can underpin better health workforce planning. The relative magnitude of shortages in the system is unclear. The National Institute for Health Development collects statistics on the number of healthcare professionals, their salary and overtime hours. However, overtime hours tend to be underreported and inconsistently measured across healthcare institutions. For example, some documentation work and handover of shifts is not included in working time (Riigikontroll, 2022). There is no regular data collection on the number of patients per doctor or nurse. To support better decision-making at the system level, the government should improve data standards and collection for workforce statistics.
Health workforce planning needs to be long-term, more coordinated, and responsive to successfully address staff shortages. The planning for training places is currently negotiated between the Ministry of Social Affairs, the Ministry of Education and Research, education institutions and healthcare organisations. The responsibility for funding education and practical training is split between two ministries. There is no long-term plan and the number of admissions for each specialty is agreed separately each year (Riigikontroll, 2022). An effective planning approach would make more use of data to forecast the demand for and supply of healthcare staff and would benefit from a dedicated budget and policy tools to boost training rates. So far, Estonia has mapped its planning system with other EU countries to identify areas for improvement and it is developing it within the scope of the EU Joint-Action HEROES project that runs until 2026. It should continue this progress.
Detecting diseases earlier and treating them faster
Mortality rates from treatable conditions have declined but remain elevated. Close to 10% of all deaths in 2019 could have been avoided through better healthcare interventions. Estonia has reduced treatable mortality by a quarter over the past decade, twice as much as the average decrease in the OECD, albeit from a high level. Nonetheless, treatable mortality remains a third above the OECD average (Figure 5.22). The most common causes of death are ischaemic heart disease, hypertension, stroke, and cancer, which remained slightly more frequent than the OECD average in 2021, despite significant improvement over the past decade. Treatable mortality tends to be comparatively worse for men. For example, cancer mortality for Estonian men was among the highest in the OECD. To reduce the number of premature deaths, it is essential to detect disease early and proceed to treatment quickly and effectively.
Deaths per 100,000 inhabitants (standardised rates)
Source: OECD Health at a Glance 2023.
The risk factors that lead to coronary heart disease, hypertension and stroke need to be better monitored. These risk factors are unhealthy diets and insufficient physical activity, obesity, high cholesterol, irregular heartbeats and diabetes. Monitoring is partly opportunistic as patients visiting their family doctors will have blood pressure and cholesterol checked. Patients are also specifically invited to participate in screening. However, many patients are not tested. For example, only half of all adults that have hypertension in Estonia were diagnosed in 2019 (WHO, 2023b). While the EHIF provides financial incentives to family doctors for chronic disease management, such payments only make up around 3% of family doctors’ earnings, whereas such incentive payments in OECD countries typically range between 5% and 15%. Moreover, most of the incentive payments in Estonia are skewed towards hypertension. Other chronic conditions, such as diabetes, should be given more attention and their screening and treatment incentivised accordingly.
Estonia should expand general monitoring of health conditions in a targeted manner. While general health check-ups are free, participation is insufficient to detect many of the risk factors early enough. In France, employees need to undergo a health assessment every five years, although those at high risk are required to be checked more frequently. In Korea, companies are required to provide health checks for employees aged 40+ (Chu, 2017). Ensuring routine health checks are targeted is important for maximising the effectiveness of such programmes (Gmeinder et al, 2017). Estonia already requires firms to provide occupational health assessments in certain sectors. To boost health monitoring, firms should be asked to extend health assessments of their older workers.
Detection of cancer still needs to improve. The incidence of cancer in Estonia is below the OECD average but mortality rates tend to be higher than the average. The most common forms of cancer are prostate, lung, breast, colorectal, uterus and cervical cancer. Estonia has been running national cancer screening programmes for breast and cervical cancer for almost two decades, while colorectal cancer screening was introduced in 2016. However, only around half of those invited attend a screening (Riigikontroll, 2021b). This is below the EU average and well below the national target of 70% (Figure 5.23). As a result, when cancer is detected, it is often detected at a later stage. For example, only around 29% of cervical cancer, 35% of colon cancer and 49% of breast cancer were detected in the early stages of the disease in 2018 (Riigikontroll, 2021a). Late diagnosis is associated with higher cancer mortality.
Screening rates, 2020
Note: The data refer to self-reported screening rates.
Source: Eurostat.
Low awareness and access to tests have led to low participation in cancer screening programs in Estonia. A key determinant of low screening uptake is the amount of previous interaction with the health system (Niglas and Haller-Kikkatalo, 2021). This is particularly pronounced among people with low income and low education (Lubi et al, 2021). There are also geographical disparities with participation varying by as much as 20 percentage points between high and low participating counties (NIHD, 2022). Estonia regularly runs public awareness campaigns and promotes nationwide cancer screening. For example, its mobile mammography buses have improved breast cancer screening in remote areas. For colorectal cancer testing, tests can be done at home and sent to laboratories by mail (OECD, 2023d). Furthermore, people who are invited but do not attend cancer screening are repeatedly reminded by phone, email and their family doctor. These efforts should be continued and intensified for less educated groups and in regions with low screening participation.
Estonia should consider broadening screening to other cancers. Currently, there are no lung or prostate cancer screening programmes. Detecting prostate cancer and lung cancer can have health costs. The rate of false positives in prostate-specific antigen tests can lead to misdiagnosis while lung screening can involve harmful radiation. A few EU countries, such as Sweden and Germany, are piloting prostate cancer screening programmes and Estonia is assessing its feasibility. For lung cancer, a recent study in Estonia concluded that family doctors and nurses could be involved in identification of long-term smokers for screening via low-dose computed tomography (Laisaar, 2022). Regional pilot programmes to assess lung cancer screening cost-effectiveness are ongoing (Tervisekassa, 2024). To the extent that local evidence points to public health benefits outweighing the costs, including possible false detection and overtreatment, Estonia should test for other cancers as well.
Treatment needs to be timelier and more comprehensive. For cancer, treatment should start within 9 weeks of diagnosis, but this was only the case with patients with breast cancer. It takes cervical, lung and colorectal patients longer than 100 days to start treatment (Riigikontroll, 2021a). More healthcare staff and equipment would help ensure faster treatment. However, waiting times need to be better monitored and, once cancer is identified, patients should be given priority at further stages of care to reduce their waiting times (OECD, 2023d). These issues have been identified in Estonia’s Cancer Control Plan 2021-30. There were initial delays in completing the plan, but its implementation is now underway (Riigikontroll, 2022).
More integrated care can contribute to lower treatable mortality. Primary healthcare providers need to better coordinate with hospitals, particularly for chronic patients (AARC, 2022). Moreover, despite having specialised cancer centres, follow-up healthcare after treatment is poor. There is a lack of awareness among healthcare professionals about rehabilitation services and psychological support due to fragmented services. Support for returning to work is not systematic (OECD, 2023d). This is evidenced by all-cause readmission and mortality after a stroke that is higher than the OECD average (Figure 5.24). There should be more integrated care across all levels of healthcare, particularly after treatment.
Establishing more patient-centred care through patient pathways can better define a patient’s journey to recovery and identify the necessary healthcare services. This can speed up treatment but also save costs and improve efficiency. Estonia has recently piloted a stroke patient pathway, which has resulted in improved health outcomes and, with bundled payments for the provided care, has led to lower costs. If fully adopted, it could lead to savings of at least 0.2% of total health spending (Tervisekassa, 2023b). Patient pathways should be broadened out to other treatable high risk health conditions. So far, the EHIF has started new pilot programmes for hip and knee replacements and is developing a pathway for mental health treatment (Kasekamp et al, 2023).
Patients with adverse outcomes within one year of discharge, 2021 or nearest year
Source: OECD HCQO Data Collection on Integrated Care 2022-23.
Boosting health through more prevention
Lifestyle factors play a significant role in weak health outcomes in Estonia, and prevention policies typically have a high return on investment. Spending on programmes that address risky behaviour and prevents people from developing disease is highly beneficial. Estonia spent 0.2% of GDP in 2019 on preventive healthcare, broadly in line with the OECD average, and this has risen to 0.6% of GDP in 2022, partly as a result of the pandemic. Since Estonia has some of the highest avoidable mortality rates in the OECD, boosting preventive spending in a targeted and cost-effective manner could improve health outcomes and raise overall healthcare efficiency. Better health can also make the population more resilient in a crisis as experience during the pandemic has shown, when people in poor health were particularly at risk (OECD, 2023f).
Preventable death rates continue to be relatively high. About a third of all deaths in 2020 were due to preventable causes, that is, they could have been mainly avoided through public health and primary prevention programmes. Estonia had made progress in reducing preventable mortality rates between 2015 and 2019 although these had increased in 2020 due to COVID-19. Preventable mortality remains well above the EU average, particularly among men (Figure 5.25).
Many preventable deaths are related to a handful of key risky behaviours. Nearly a fifth of all deaths could be attributed to dietary risks, while physical inactivity accounted for 2%, broadly similar to the OECD average (OECD, 2023a). Tobacco use (including second-hand smoke) is the second most important behavioural risk factor contributing to mortality, accounting for 15% of deaths, although smoking is less prevalent than in other OECD countries. However, alcohol consumption is among the highest in the OECD (Figure 5.26). Alcohol consumption was responsible for 8% of all deaths in 2019, and alcohol-related mortality increased during the COVID-19 pandemic (NIHD, 2023).
Standardised death rates for preventable diseases/conditions, persons aged less than 75 years, by sex, 2020 (per 100 000 inhabitants)
Source: Eurostat.
2021
Source: OECD Health at a Glance 2023.
Alcohol consumption is high. Alcohol dependency rates are some of the highest in the OECD, with around 10% of men addicted to alcohol (OECD, 2021b). Estonians tend to drink beer and spirits consuming 11.1 litres of pure alcohol per person in 2022, which was among the highest in the OECD (Figure 5.27). Around 40% of adults engage in heavy drinking each month, defined as consuming six or more drinks on a single occasion, with men drinking three times more alcohol than women. Harmful alcohol use leads to many non-communicable diseases and premature deaths. It lowers economic growth through lower employment and productivity. According to OECD simulations, on average, excessive alcohol use is estimated to pull down on life expectancy by 1.5 years, push up on health expenditure by 3.5%, and lower the level of GDP by 3.4%, by 2050 (OECD, 2021d).
Comprehensive policies have reduced alcohol consumption. Since alcohol use reached 14.8 litres per person in 2007, Estonia restricted advertising, banned late night off-premises alcohol sales, introduced awareness campaigns, stepped up random breath tests among drivers and established yearly increases in excise duties. After comprehensive consultation, it adopted an official policy on alcohol in 2014, aiming to eventually reduce consumption to 8 litres per person per year. This was accompanied by further increases in excise tax, wider restrictions on displays in shops and stricter advertising (WHO, 2019). Tighter policy had been successful in reducing alcohol consumption to 10.4 litres by 2019. However, further increases in excise taxes were scrapped in 2019 as large alcohol price differentials between Estonia and Latvia had led to a four-fold increase in cross-border trade limiting the effects of excise taxes as a policy tool (WHO, 2023a). Alcohol use increased during the pandemic reversing some of the gains made.
Alcohol prices should be increased. The most effective policies tend to be financial measures such as excise taxes and minimum unit prices on alcohol. In Estonia, alcohol affordability has increased in recent years due to rising incomes (NIHD, 2022). The government is planning to raise excise duties by 5% per year in 2024-2026. These taxes should be indexed to inflation and real income growth to ensure a persistent reduction in affordability levels. Estonia should coordinate health policies with Latvia to avoid widening price differentials and an increase in cross-border trade (WHO, 2023a). This will be important to ensure that higher excise duties are effective given that 41% of the population went to Latvia specifically to purchase alcohol 4 times or more during the year (NIHD, 2022).
Consumption of alcohol among the population aged 15 years old and over (litres per capita)
Source: OECD Health at a Glance 2023.
Excise duties per hectolitre of absolute alcohol as a share of annual average wages, 2022
Note: The excise duties refer to tax per hectolitre of absolute alcohol in alcoholic beverages other than beer and wine.
Source: OECD Tax Trends 2022, OECD database and OECD calculations.
Alcohol availability can be restricted further. Sherk et al (2018) found that one additional day of sales leads to a 3.4% increase in total per capita consumption of alcohol. Hours should be restricted further by, for example, banning sales on Sundays as done in the Nordic countries or by restricting on-premise hours such as in Lithuania. The density of alcohol sales outlets could also be lowered. The number of shops selling alcohol is more than twice as high than in Finland, Sweden or Norway and 88% of Estonians are a 10-minute drive away from a shop selling alcohol (NIHD, 2022). Latvia restricted sales in petrol stations, while Lithuania banned sales of strong alcohol on beaches and in pavilions (OECD, 2021d). A longitudinal analysis by Brenner et al (2015) found that a one standard deviation decrease in outlet density resulted in a 7% fall in alcohol consumption for men and 11% for women. This should be complemented with further restrictions in advertising. Social media regulations forbid alcohol advertising on social media networks, except on alcohol brands’ official accounts. Alcohol brands cannot share user-generated content or content that is intended to be shared. However, Estonia does not have any restrictions on alcohol brands sponsoring sports. In response to public health concerns, most OECD countries have implemented some form of ban to restrict the alcohol industry’s influence in sport. For example, Spain, France, Norway and Türkiye have implemented legally binding bans on sport sponsorship across all beverages (OECD, 2021d).
Smoking has become less common but still remains a public health risk. Smoking rates have fallen from 26% in 2009 to 16% in 2022. Smoking continues to be more prevalent among men who are twice as likely to smoke daily than women. However, regular use of vaping products rose to 10.4% in 2022, the highest in the OECD (Figure 5.29). This was mostly driven by young adults aged 15-24. Policies should continue to restrict tobacco use. Excise taxes, one of the most effective policy tools to disincentivise tobacco use, have been rising by 5% in recent years and the government will continue increasing them by 5% annually between 2024-2026 (OECD, 2015). To help long-term smokers quit, Estonia should invest more in smoking cessation campaigns carried out by primary care providers to target male smokers.
Share of population aged 15 years old and over
Note: 1. Data from 2019. 2. Data from 2018.
Source: OECD Health at a Glance 2023.
Compliance with regulations on tobacco sales needs to be strengthened. The 2017 Tobacco Act bans the use and possession of combusted cigarettes and vaping products by minors under the age of 18 (Snell et al, 2018). But enforcement of rules is too lax in Estonia. A recent study by the National Institute for Health and Development found that e-cigarettes are easily available to minors. In special e-cigarette stores and small shops, no documents were requested when purchasing e-cigarettes in 40-50% of cases tested, although this decreased in larger stores and petrol stations. Younger employees asked for proof of age less often than older employees. Moreover, visible notices about sales bans of e-cigarettes to minors were present in only 30% of larger stores (Mall and Tarlap, 2023). To increase compliance with the rules, supervision and application of higher fines for repeated violations is needed.
In 2019, more than half of all adults in Estonia were overweight, above the EU average (Figure 5.30). Overweight and obesity rates are increasingly becoming an issue for adolescents, as the rates have increased substantially over the past two decades, reaching 19% in 2018 among 15-year-olds, up from only 7% in 2002 (OECD/WHO, 2023e). The rise in obesity can be ascribed to increasingly unhealthy lifestyles, including a poor diet and nutrition, and insufficient levels of physical activity and sedentary behaviour (OECD, 2019). Overweight adults and associated diseases such as diabetes, cardiovascular diseases and cancer lead to worse outcomes across a range of measures and higher health spending. Estimates show that such conditions could reduce life expectancy by 3.3 years between 2020 and 2050, reducing the level of GDP by 4% due to lower employment and productivity, above the OECD average (OECD, 2019).
Overweight (including obesity) rates among the adult population, by gender, 2019
Note: Adults defined as people aged 18 years old and over. The EU average is weighted. No data is available for Ireland.
Source: OECD Health at a Glance EU 2023.
Prevention policies that aim at improving nutrition and boosting physical exercise, both key determinants of obesity, tend to have a high return on investment and could reduce these potential costs (OECD, 2019). Estonia has an action plan on adult and child obesity and has developed national food and dietary guidelines to help people make better nutritional choices. The National Institute for Health Development collects data on nutrition and exercise, conducts research, and supports public policy through advice, training and informational campaigns. In schools, meals are provided for free and volumes of salt, fat, and sugar are regulated. However, nutrition still needs to improve. Although the share of people who eat fruit and vegetables has consistently risen over time, fewer than one in seven adults in Estonia consume at least five portions of fruit and vegetables per day, recommended by the WHO as a key element of a healthy diet (OECD/WHO, 2023e). Recent measures have gone further by implementing a voluntary code on responsible food marketing to children in 2023 (Ringhaaling, 2023).
The relative price of an unhealthy diet should be increased. Raising the relative price of unhealthy food and drinks can improve nutrition through lower consumption of unhealthy products and lead to improved nutritional composition of food and drinks. Many OECD countries such as Finland, France, and the United Kingdom tax sugary drinks and this has been found to reduce sugar consumption (Griffith et al, 2019). The Estonian Parliament approved legislation taxing sugar in soft drinks in 2017, but this was not implemented by the government. Estonia should introduce a sugar tax. More broadly, taxes on unhealthy foods are less common in OECD countries but Mexico and Hungary have introduced them. In 2011, Hungary introduced an excise levy on the salt, sugar, fat, and caffeine content of pre-packaged foods for which there were healthy alternatives. Some studies have suggested that this had led to lower consumption of the targeted products, particularly by overweight and obese consumers (Giles et al, 2019). It also resulted in manufacturers reformulating products where taxes exceeded a minimum threshold, leading to a reduction or removal of sugar or fat content (Wright et al, 2019).
Food labelling could further improve to steer people towards healthy choices. Currently, nutrition label standards and regulations refer only to EU regulations, but more can be done at a national level (WCRF, 2023). Estonia only has a mandatory back-of-pack nutrition label, but front-of-pack labels can be more effective in influencing people’s dietary choices (OECD, 2019). For example, Sweden operates the Keyhole logo, a voluntary scheme, that allows business to label products if they have less fat, sugar or salt, dietary fibre and whole grains, compared to other foods in the same category. In France, businesses can voluntarily apply a Nutri-Score label based on a five-colour scale that summarises the healthiness of a product, and provides a single, compound score (OECD, 2019). This can be particularly effective in encouraging healthier food choices (EUPHA, 2023). There are no health warnings on food products in Estonia. For example, as part of its mandatory labelling system for pre-packaged foods, Chile requires products that exceed calorie, salt, sugar, or fat thresholds to have health warnings. Furthermore, nutritional information should also be extended to restaurant menus as this can also help lower calorie intake (OECD, 2019).
Increased physical exercise needs to accompany better nutrition in order to reduce overweight and obesity rates. Insufficient levels of physical activity can make chronic health conditions, such as cardiovascular disease, diabetes, and back pain, more likely. Time use survey data suggests that time spent on physical exercise each day increased to an average of 40 minutes in 2019-2021, which is a third more than ten years ago (Statistics Estonia, 2023). While some people exercise enough, only a minority of Estonians exercised 150 minutes per week or more in 2019, a minimum threshold for sufficient physical activity recommended by the WHO (Figure 5.31). Physical exercise among adolescents is also insufficient, despite more than half of the children participating in organised sport (Maestu et al, 2022). In 2018, a little under 15% of 15-year-olds exercised at least one hour per day recommended by WHO, around the OECD average (OECD/WHO, 2023).
Raising physical activity levels among adolescents is important. A new physical education curriculum was accepted by the government at the start of 2023 and is being implemented by the Ministry of Education and Research with priority (Maestu et al, 2023). However, there needs to be more emphasis on increasing the opportunities for children to move. In Estonian schools, it is not very common to have outdoor recess throughout the year, although this is increasing slowly. Boosting outdoor time can lead to more physical activity. A good example of such a policy is Estonia’s “Schools in Motion” programme (see Box 5.4 for more details), which should be broadened to more schools. The government should invest more in infrastructure to raise the availability of playgrounds. While 92% of schools have a sports hall, it can only be used outside of school time in a third of all schools. Moreover, local governments should promote general and recreational sport activities through youth sport associations to attract more children, particularly during puberty when many drop out as they lose interest in competitive sports (Maestu et, 2023).
Share of adults reporting time spent on enhancing (non-work related) aerobic physical activities, 2019
Note: Adults defined as people aged 18 years old and over. The indicator of insufficient physical activity is defined as attaining less than 150 minutes of moderate‑intensity physical activity per week, or less than 75 minutes of vigorous-intensity physical activity per week.
Source: OECD Health at a Glance EU 2022.
In 2016, Estonia started a “Schools in Motion” programme with the aim of boosting physical activity among children. The programmes take a whole-school approach, covering physical education, active recess, active lessons and active transport to and from school (Mooses et al, 2021). Participating schools are supported through seminars, workshops and skills training, and have access to easy-to-use materials and research, for example, tips on how to make the indoor and outdoor environment more physical activity friendly, and techniques for reducing sedentary time during classes. Using these resources, each school can develop their own action plan.
The programme has been successful. The number of participating schools increased from 10 in 2016 to 209 in 2023, accounting for 28% of all general education schools and more than 63,000 students. Many schools that joined the programme did not initially have outdoor recesses but by 2020 three quarters offered it, leading to a near doubling of students that had access to at least 20 minutes of an active break.
Source: Education Estonia (2023).
Existing policies to boost physical exercise among adults should be expanded. Estonia updated its national guidelines on nutrition and physical activity in 2017 and has a strategy for sports policy until 2030. It has promoted exercise through annual European Week of Sports since 2015 and organised “Kondimootriga Tööle” (Walk2Work) campaigns. Since 2018, companies could claim up to EUR 400 of health and sports expenses per employee each year as tax-exempt benefits. Workplace-based interventions are increasingly considered as an effective tool to influence lifestyle (OECD/WHO, 2023e). Estonia could expand informational campaigns to also boost cycling to work and complement this with a government-sponsored cycle to work scheme introduced in other OECD countries like the United Kingdom. More importantly, Estonia should renew its push to boost physical activity by finalising the green paper on physical activity that has been in development since 2014.
Healthcare interventions could drive obesity rates down. For high-risk groups, physical activity prescription programmes run by family doctors, nurses or other health professionals could boost physical exercise. While doctors in Estonia can provide counselling on nutrition or brief interventions, there is scope to expand and align with best practices. For example, Sweden has been running such programmes for 20 years and they have proved to be effective (OECD, 2022). Such interventions are now being implemented in nine other EU countries with EU funding support (OECD/WHO, 2023e). In the Netherlands, health insurance covers a broader combined lifestyle intervention for overweight and obese patients. Doctors in primary healthcare refer patients to programmes which are provided by lifestyle coaches, dieticians, physiotherapists or exercise therapists. Participants receive diet and physical activity advice, as well as structured exercise classes over a two-year period (RIVM, 2023).
Mental health problems remain significant. One in four adults was at risk of depression in 2022 according to the Estonian National Mental Health Study (NIHD, 2022). Lower income groups, particularly men, are more likely to report chronic depression. Suicide rates remain high with male suicide rates higher than the OECD average (Figure 5.32) (OECD, 2023b). Around a quarter of unmet health needs were related to mental healthcare in 2021-22 (Eurofound, 2022). The economic cost of mental disorders is substantial and previous estimates put the cost at 2.8% of GDP in 2015 (OECD/EU, 2018).
Deaths per 100 000 inhabitants (age-standardised rates), 2020 or latest available
Note: Latest available data for Norway and New Zealand 2016; Italy and France 2017; Ireland, Sweden and Belgium 2018; and the Slovak Republic, Portugal, Canada and Hungary 2019.
Source: OECD Health at a Glance 2023.
Renewed efforts are aiming to improve mental health and should be fully implemented. In 2021, the Green Paper on Mental Health was completed and the following year the Mental Health Action Plan for 2023-26 was put in place. The policies aim to create a comprehensive, intersectoral and multi-level mental health system. The EHIF started reimbursing family doctors for e-consultations for mental health diagnosis and treatment in 2021 and psychiatric help for people under 18 has become available without the consent of a legal representative. A mental health department was established within the Ministry of Social Affairs in 2022, while total funding for mental health services more than tripled to EUR 7 million (Ministry of Finance, 2022). Estonia is also developing its first suicide prevention action plan. This progress should be continued, but to fully reap the benefits of these policies the authorities should also run a national awareness campaign to introduce the new range of support services. It will also need to ensure that a sufficient number of staff specialised in mental healthcare is available, as discussed in Section 5.4. This will improve mental health, as well as resilience, as the pandemic has shown how mental health particularly among young people can deteriorate quickly in a crisis (OECD, 2023f).
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