The treatment and monitoring of patients with hypertension in Estonia is not consistent, which means that there is insufficient support for preventing complications and reducing the risk of more serious cardiovascular diseases. According to the analysis conducted by the National Audit Office, only about a third of first-time patients achieved the target blood pressure prescribed in the treatment guidelines within 2–3 months, and the treatment of about a third of patients was interrupted within six months of diagnosis. Also, not all patients visit their family physicians as often as required in the treatment guidelines and do not follow the prescribed treatment. The tests and analyses specified in the treatment guidelines are often not performed, and the counselling meant for the improvement of treatment adherence was documented in only 18% of the cases.
Poor management of hypertension causes a significant disease burden. Therefore, the Ministry of Social Affairs, together with the Health Insurance Fund, must develop an arrangement of work that supports consistent adherence to the treatment guidelines, ensures compliance with the requirements for the monitoring of patients with hypertension and divides the tasks related to the treatment of patients between primary care specialists more clearly.
Main observations
The Ministry of Social Affairs and the Health Insurance Fund have failed to organise primary health care in a way that ensures consistent and uniform compliance with the guidelines for the treatment of hypertension. Although the treatment guidelines clearly define the principles of diagnosis, treatment and counselling, there is no systematic monitoring of their implementation and no corrective action in situations where the guidelines are not followed. The performance of the tests, analyses and counselling, as required by the treatment guidelines, varied by region and was somewhat better among the family physicians who had met the criteria of the Primary Health Care Quality Bonus System.
The Health Insurance Fund does not use its management and motivation levers enough to support the treatment adherence and treatment consistency of hypertension patients. There are no automated reminder and monitoring systems to give family physicians a comprehensive overview of their chronic patients’ condition and medication use and, on the other hand, to support the treatment adherence of patients. During the six years surveyed, only 37% of patients had annual contact with their family physician or nurse, and even patients who came in for an appointment did not always receive all the tests they needed and were not always advised. About half of the patients had not bought enough medicines to last them for the whole period under review. Activities for regular monitoring of patients with hypertension are agreed in the Primary Health Care Quality Bonus System, but not all family physicians perform them and nothing follows from not fulfilling the criteria.
The management of hypertension cannot be limited to family physicians alone, but the Ministry of Social Affairs has so far failed to organise the systematic involvement of other primary care actors, such as occupational health specialists or pharmacists, in the early detection and counselling of chronically ill patients and the supporting of treatment adherence. Currently, there is no effective solution that would allow occupational health specialists and pharmacists to communicate information about a patient’s health risks or the results of a blood pressure measurement to family physicians. Therefore, patients with high blood pressure detected outside the family medicine setting may not always receive follow-up monitoring their family physicians.
The actions taken by the Ministry of Social Affairs so far have not been systematic enough to prepare the health system for the growing burden of chronic patients. Although the problems of high blood pressure have been known for years, the Ministry has not set specific targets, indicators or systematically addressed the need to strengthen the treatment of patients at the primary health care level. Little attention is given to the prevention of morbidity and complications, patients’ awareness is low, and access to and use of lifestyle support services is limited.
Main recommendations of the National Audit Office
Recommendations of the National Audit Office to the Minister of Social Affairs in cooperation with the Chairman of the Management Board of the Health Insurance Fund:
- Ensure that family physicians follow the guidelines for the treatment of hypertension and assess compliance regularly.
- Create IT solutions to support the monitoring of patients with chronic conditions – including automated reminders for both family physicians and patients, a treatment plan that is visible to all parties, and monitoring of treatment adherence.
- Create solutions to improve the exchange of information between family physicians, occupational health specialists and pharmacists to ensure seamless treatment management.
Recommendations of the National Audit Office to the Minister of Social Affairs in cooperation with the Chairman of the Management Board of the Health Insurance Fund and Director of the National Institute for Health Development:
- Decide which behavioural risk factors justify the provision of services through the health system and in which cases would it be more beneficial to engage other specialists in addition to health professionals, taking into account the limited resources of the health system and the need to avoid further increasing the burden at the expense of medical services.
- Set clear targets, indicators and accountability for the prevention and management of hypertension and other cardiovascular diseases to ensure coordinated management and evaluation of the effectiveness of policy measures
The Minister of Social Affairs replied that treatment guidelines are optional in Estonia and the physician can deviate from them if justified . However, adherence to treatment guidelines is an important quality indicator, but the Ministry does not monitor it separately. The Health Board assesses service providers on a case-by-case basis and checks that diagnosis and treatment are properly documented and in line with current medical knowledge.
According to the Minister, a health plan function will be created in the Health Portal and the Healthcare Specialist Portal in 2026, which will bring together treatment objectives and activities, and will be accessible to both health professionals and patients. The creation of digital solutions to improve the exchange of information between occupational health specialists and family physicians is also being considered. One of the objectives of the occupational health development strategy that is currently in development, is to agree on a model for cooperation between occupational health specialists and family physicians.
The plan is to involve a wider range of specialists and develop interventions to reduce risk factors such as low physical activity and obesity, in order to reduce the burden on the health system.
The National Health Plan sets targets and indicators to reduce alcohol consumption and promote a balanced diet and physical activity. A new funding model for primary care was implemented in 2026 and strengthening the performance-based Primary Health Care Quality Bonus System is under discussion.
The Chairman of the Management Board of the Health Insurance Fund agreed with the recommendations of the National Audit Office, including that the quality of primary care is uneven. A new funding model for family medicine was implemented in 2026. The Primary Health Care Quality Bonus System will be developed at the same time to move from performance-based assessment to the assessment of treatment outcomes, using updated treatment guidelines, decision support, health plans and a data-driven Primary Health Care Quality Bonus System.
Centralised digital solutions, such as Healthcare Specialist Portal, the Health Portal and decision support have been developed to better monitor patients with hypertension, and the foundation has been laid for the use of automated patient reminders and a treatment regimen solution. The introduction of a centralised national health plan is planned for the future, but further developments will depend on priorities and legal agreements with partners.
According to the Health Insurance Fund, the prevention of cardiovascular diseases and lifestyle services are not yet organised systematically enough in the Estonian health system. The primary role of the Health Insurance Fund is to organise and finance evidence-based prevention services and to move towards risk-based prevention, focusing on people with higher risk.
At the same time, the health sector needs broader all-round management, which requires national coordination from the Ministry of Social Affairs and a clear division of roles between stakeholders, which cannot be the sole responsibility of the Health Insurance Fund.
The Director of the National Institute for Health Development agreed with the recommendations of the National Audit Office. The Institute develops and supports primary prevention activities through training, the creation of new intervention models and data-driven monitoring. The development of the prevention system, including preventive services, is one of the priority areas of the Ministry of Social Affairs.
The roles of different stakeholders are generally defined in the programmes of the National Health Plan, but as there is no specific action plan for cardiovascular disease management, there is no coherent coordination between agencies. The assessment report of the effectiveness of the health system, which will be completed in June 2026, will address resources, outcomes, etc. at a general level, but more specific assessment reports on diseases will be prepared in the future.
The integration of the database of the Health Insurance Fund and the Estonian Medical Prescription Centre with the Health Information System is currently underway in order to simplify the transmission and use of health data. Amendments to the Official Statistics Act are also planned to make it possible to use more data sources and establish a health statistics programme to ensure systematic collection and monitoring of health indicators and to support evidence-based management decisions.