Mainly because of a shortage of healthcare professionals and partly also because of the lack of finances, people in Estonia will probably have to accept in the near future that the availability and/or quality of health services will not be uniformly at the expected level. However, the decisions necessary for functioning under the new conditions and for reorganisation are still pending.

As Estonia is a country with a shrinking and ageing population, where it is predicted that one in four people will be of retirement age by 2035, and the growth rate of disability free life expectancy has so far been slower than expected, a greater need for medical services and resources is foreseeable in the future.

The long-term development strategy "Estonia 2035" adopted by the Estonian Parliament (Riigikogu) states that Estonia spends 6.7% of GDP on healthcare, which is, however, almost three percentage points below the average of the European Union, and even if the current level of services is maintained, the Estonian Health Insurance Fund’s costs will increase almost 24% faster than revenues by 2035. The Foresight Centre is a think tank of the Riigikogu that analyses long-term developments in society and the economy. Its 2020 analysis states that citizens' copayments could double by 2035, queues for treatment will become longer and the Health Insurance Fund’s budget will reach a deficit of 900 million euros if no changes are made to the system. Therefore, the discussion on the topic of revising the financing principles of health insurance will probably become increasingly urgent in the near future (see overview of financing in Appendix A).

Over the years, the National Audit Office has often highlighted the ills of the healthcare system, stressing that timely identification of health problems, starting treatment and getting it right are central to extending healthy life expectancy and improving people's quality of life. Healthcare is an area that affects all aspects of social life, because human capital is the greatest asset of any country, and it must be preserved and developed.

This year's annual report provides Parliament with a comprehensive overview of changes and future trends in the issues that the National Audit Office has analysed in audits of the healthcare sector since 2015.

1. In the healthcare sector, the worsening shortage of healthcare professionals has become a bigger problem than the lack of money.

The shortage of healthcare professionals has become one of the central problems in the healthcare sector. There is a particularly high shortage of nurses, psychiatrists, emergency medicine doctors and family physicians. Overtime is also widespread in the healthcare sector. Various crises have further increased the risk of a shortage of healthcare professionals, as well as overload and burnout among them. The shortage of healthcare professionals and their overload have been talked about for a long time, but there is no quick solution in sight – if anything, the problems are getting worse. Here are some examples.

• The number of lists without family physicians is increasing, and the temporary substitute doctor in family medical care is becoming an increasingly permanent phenomenon. In the 2020 annual report, the National Audit Office pointed out that there are more family physicians retiring than the vacancies can be filled. Nearly half of all family physicians were and are 60 years old or older, i.e. they are already at retirement age or can retire in the near future if they wish. It is becoming increasingly difficult to find new doctors for the family physician list: in the first half of 2022, nearly 75% of family physician competitions failed. In the same period, 54 lists had a substitute doctor, of which 13 lists have had a temporary solution for five or more years. For patients, this may mean that the substitute doctor is not there for them when needed and does not know the patients on the list well enough. The increase in the proportion of substitute doctors contradicts the essence of family medical care. 
  The Family Physicians Association of Estonia, the Health Board, the Estonian Health Insurance Fund, and the Ministry of Social Affairs consider the optimal size of the family physician list to be 1,600 people. According to this, there is a shortage of at least 45 family physicians in Estonia.
• Psychiatrists and other mental health specialists would be needed, but it is difficult to maintain the current level. According to the National Institute for Health Development, 222 psychiatrists worked in Estonia in 2021, including 18 child and adolescent psychiatrists. So there were approximately 15 psychiatrists per 100,000 people. In 2019, this ratio was 16, and then the Estonian Psychiatric Association estimated that 30–40 more psychiatrists were needed. Additional 130–160 clinical psychologists would be needed for primary (first contact) care level. There is also a shortage of school psychologists and mental health nurses. 
  In addition to the actual need described above, maintaining the current number of specialists has also become a problem. Half of the psychiatrists are already of retirement age or will soon reach it. Therefore, the shortage of psychiatrists is very great and one can speak of a labour crisis in this area.

The recent increase in the training mandate for healthcare professionals has been important, but it was done too late. There are also difficulties in filling study places in some disciplines because the work is stressful and this discourages young people from choosing a profession. In addition, not all students complete their studies and education takes a long time. Therefore, an increased number of study places will not help to alleviate the need for healthcare professionals in the near future. The training mandate needs to be increased in the future, and it is important to make the less popular specialties more attractive. It is necessary to bring forth an innovation with which it will be possible to somewhat reduce the need for human labour.

2. Disease prevention and early detection have received little attention in recent years.

Untreated diseases will be reflected in people's lost years of life and work in the future. As a result, treatment time is prolonged, the risk of complications increases, people are removed from an active life, and the financial burden on the healthcare system increases.

The National Audit Office has investigated changes in children's participation in medical examinations, school healthcare, and vaccinations, and in adults' participation in screenings and visits to the dentist. In these matters, the situation has not improved in recent years. Furthermore, health promotion was not sufficiently addressed during the pandemic COVID-19 and more attention needs to be paid to this area in the future.

• Children’s health problems go unnoticed because a large number of children do not go for medical examinations. The state has prescribed medical examinations at specific intervals for early discovery of illnesses. While 88–96% of children of up to 2 years of age underwent regular medical examinations, the number was only 6% among 3–6-year-olds. However, 43% of children between the ages of 3 and 6 remained completely out of sight of a health care professional for years, because they never underwent a medical examination.
• Early detection of health problems is also hindered by the lack of school nurses. Because a school-age child spends a large part of their day in school, both health promotion and monitoring of health should be a part of the school life for all children. The established requirement – one school nurse per 600 pupils – cannot be met everywhere. For example, in 2021, among 90 schools, there were 55 schools with more than 600 pupils, and only one school nurse was serving them. In 2016, there were 42 such schools. One reason for the worsening situation is the general shortage of nurses.
• Refusal to vaccinate children is increasing and this can lead to the return of dangerous diseases. As a result of previous successful vaccination, quite a few dangerous diseases have almost disappeared from Estonia. Unfortunately, the refusal of vaccination has increased. Depending on the vaccine, in 2014 there were 1.9–3.5% of people who refused vaccination, but in 2021 the number had increased to 3.8–7.8%.
• The dental care benefit, where everyone is treated equally, has increased inequality in dental care. Following the entry into force of the dental care benefit for adults in 2017, the number of people attending the dentist for the first time and the number of people who visited the doctor more often increased. However, the benefit was used more by people with higher incomes who would be able to pay for dental care themselves. On the other hand, between 2016 and 2021, about 40% of adults, mostly people with lower incomes, never visited a dentist. Only about 4% of recipients of subsistence benefits claimed dental care benefit.
  Inequalities in dental care have increased because current benefit conditions do not protect people with high medical needs from high healthcare costs. For a person in high need for treatment who has to visit the doctor repeatedly, the total co-payment is 70–85%. People with lower incomes cannot afford such a high co-payment. It would help them if the income and healthcare costs of each individual were taken into account when granting benefits.
• Participation in cancer screening tests is low, and the start of cancer treatment is delayed. Although every week that treatment is delayed reduces a cancer patient's chance of survival by 1–3%, cancer in Estonia is often discovered at a later stage. Poor participation in health screening is one of the reasons why malignant tumours are detected too late. Participation rate in screening is considerably below the 70% agreed in the Cancer Control Plan, reaching 59% for breast cancer, 51% for cervical cancer and 48% for colorectal cancer in 2021.
  Even after a malignant tumour has been detected, there still might be delays in treatment at different stages. According to the Cancer Control Plan, the duration of the patient’s pathway from cancer suspicion to first treatment should be a maximum of 63 days. In reality, only breast cancer patients started cancer treatment on time (within 52 days, on average). It took approximately 100 days for cervical and lung cancer patients and 122 days for colorectal cancer patients.

3. Access to health services is still inconsistent across counties and specialties.

In an international comparison, people in Estonia rate their unmet need for health care highest compared to estimates from other countries in the European Union. At the same time, treatment started at the right time is more effective and less costly, while later treatment reduces the number of disability free live expectancy, increases the subsequent volume of health services and requires more complex treatment. Already, the limited availability of specialist care and family medical care means that patients who should be treated either in a hospital or by a family physician end up in inpatient nursing care and in the Emergency Medicine Department (EMD).

• Estonia is estimated to have the greatest unmet need for health care in the European Union. Although the unmet need for health care as estimated by the Estonian population has somewhat decreased in 2021 compared to previous years, it is still the largest in Europe (12.6%, the average of the European Union countries was 4.8%). Due to the lack of healthcare professionals and other resources, people cannot get to a doctor on time as queues for treatment are long.
  In Estonia, the maximum length of the waiting list for outpatient specialist care is 42 days. In 2021, 23% of patients who made an initial reservation did not arrive at their appointment within this time. In reality, the waiting time for an appointment can be longer than the measurable length of the queue, as in some cases it is not possible to book an appointment because there are no free appointments.
• The EMD continues to be the place to address bottlenecks at other levels of health care, but it is expensive and a burden on the system. 57% of visitors to the emergency medicine department have minor health problems and mostly do not need the EMD service. The main reason for this is the patchy availability and inconsistent quality of family medical care and the long queues for specialist care. However, this leads to overwork in emergency medicine departments, which prevents the rapid admission of patients requiring emergency care.
• Patients with increasingly complex conditions come to inpatient nursing care. The reason for this trend is the deficient availability of specialised and family medical care. Due to the shorter duration of inpatient treatment, the patient is referred to nursing care more quickly. Family physicians often do not assess whether patients with these more serious health problems need nursing care or do not update their treatment plans.
  In addition, in nursing care, the problem for people is the high copayment, which is why they cannot always afford the service at the desired time or in the necessary volume. COVID-19 also affected the availability of inpatient nursing care, as some hospitals temporarily removed beds to use them for treating patients with COVID-19.
  However, the aforementioned bottlenecks create additional tasks for nursing care. It is positive that the availability of home nursing has increased. However, its further expansion is limited by the shortage of nurses.

4. There is a big gap between the goals of the health sector and the actual possibilities and results.

There is a relatively broad consensus on the directions and goals of the health policy formulated in the "Estonia 2035" strategy and the Public Health Development Plan. Beneath the surface, however, lurk many unresolved questions or even contradictions. In other words, the plans are ambitious, but the way to reach the goals has not yet been determined and/or for related reasons (weak leadership and coordination, lack of resources), there is no agreement on how to reach the finish line.

• There are major challenges, such as ensuring the sustainability of healthcare financing or reforming the hospital network, for which the solutions have been too slow. The development of hospital network is a critical area where policy is stuck in the research or analysis phase. The last hospital network development plan ended in 2015, but it is not known when the new plan will be completed. The problem is that there is no agreement on the optimal number and location of hospitals for Estonia now and in the future. At the same time, the number of specialties in county hospitals has decreased due to the lack of healthcare professionals.
• The healthcare sector is characterised by solving problems in small steps, but people expect more. For example, the development of e-solutions and telemedicine services, as well as the review of treatment pathways, are welcome developments that help to address concerns about inconsistent access to health services. However, it does not solve the main bottleneck that hampers the provision of health services – there is still a shortage of healthcare professionals. Gradual changes bring us closer to the goals, but, as long as fundamental decisions at the level of the system are not made, the impact of individual development projects is limited and temporary solutions become permanent, there is a risk of duplication, etc.

What next?

The most general question is how to reduce the gap between the vision of health development plans and actual results.

In Estonia, it is not analysis or the big picture that is lacking, but the ability and courage to implement the agreed goals. Major problems must be addressed actively and comprehensively at every level of decision-making. First of all, this requires very good administrative skills. Capacity development must be a deliberate and systematic activity, the bar must be raised in all aspects of administrative capacity: the presence of experts, their knowledge and skills, well-functioning institutions and processes, money, etc. Secondly, addressing the major challenges in the health sector requires a clear will and decisive leadership.

Ultimately, the question boils down to whether or not society has time to postpone the resolution of known decision points. Success is not always guaranteed when the action is taken. At the same time, it is quite certain that not taking decisions will lead to having to make concessions on the quality and availability of health services.