Kas tervishoiuteenused on inimestele taskukohased? Uued tõendid rahalise kaitstuse kohta Eesti tervisesüsteemis 2023

Käesolev ülevaade ilmub riigipõhiste uurimuste sarjas, kus avaldatakse uusi tõendeid inimeste rahalise kaitstuse kohta Euroopa ja Kesk-Aasia tervisesüsteemides, käsitledes tervishoiuteenuste taskukohasust. Rahaline kaitstus on kõikse tervisekaitse keskne aspekt ja tervisesüsteemide toimivuse põhimõõde. Eestis on rahaline kaitstus aastatel 2015–2020 seoses positiivsete muutustega ravikindlustuspoliitikas ja muude asjaoludega paranenud. Katastroofiliste tervishoiukulude tase Eestis on siiski jätkuvalt kõrgem kui paljudes teistes Euroopa Liidu riikides ja selle peamine põhjus on suur omaosalus ambulatoorsete ravimite ostmisel ja hambaravis. Eriti suur on katastroofiliste tervishoiukulude osatähtsus madala sissetulekuga leibkondade segmendis. Ka katmata ravivajaduse tase on Eestis WHO Euroopa piirkonna keskmisest palju kõrgem, mis on tingitud pikkadest järjekordadest eriarstiabis. Eesti ravikindlustuse kõigis kolmes mõõtmes esineb lünki, mis õõnestavad rahalist kaitstust ja mõjutavad ennekõike madala sissetulekuga leibkondi. Kuna tööealise elanikkonna õigus ravikindlustusele on seotud ravikindlustusmaksete tegemisega, on 10% Eesti tööealisest elanikkonnast ravikindlustuseta. Tervisekassa hüvitiste pakett on küll üpris suur, kuid täiskasvanute hambaravi hüvitised on siiski piiratud. Eesti valitsus on püüdnud omaosalust ambulatoorsete ravimite ja hambaraviteenuste puhul vähendada, kuid madalama sissetulekuga inimestele sellest piisanud ei ole. Rahalise kaitstuse parandamiseks võiks Eesti teha järgmist: siduda ravikindlustuse saamise õigus residentsusega; suurendada ja täpsustada hüvitisi, et need jõuaksid inimesteni, kes vajavad neid kõige rohkem; vähendada omaosalust pikaajalises õendus- ja hooldusabis; ja suurendada rahalist kaitstust omaosaluse eest üldiselt, eriti madala sissetulekuga leibkondade segmendis.

Can people afford to pay for health care? New evidence on financial protection in Estonia 2023

This review is part of a series of country-based studies generating new evidence on financial protection – affordable access to health care – in health systems in Europe and central Asia. Financial protection is central to universal health coverage and a core dimension of health system performance assessment. Financial protection improved in Estonia between 2015 and 2020, reflecting positive changes in coverage policy and other factors. However, catastrophic health spending continues to be higher in Estonia than in many European Union countries – mainly driven by out-of-pocket payments for outpatient medicines and dental care – and is heavily concentrated among households with low incomes. Levels of unmet need for health care are also well above average for the WHO European Region, reflecting long waiting times for specialist care. Gaps in all three dimensions of health coverage undermine financial protection in Estonia and systematically affect households with low incomes. Linking entitlement to payment of contributions leaves 10% of working-age people without coverage. The benefits package – while quite broad – provides limited coverage of adult dental care. The Government has tried to protect people from co-payments for outpatient prescribed medicines and dental care but these efforts have not been sufficient for people with lower incomes. To improve financial protection, Estonia can change the basis for entitlement to residence; increase and fine-tune benefits to better target those in most need; reduce out-of-pocket payments in long term health care; and increase protection from all co-payments, especially for households with low incomes.

Estonia: Health System Review.

This analysis of the Estonian health system illustrates recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In general, Estonia spends less per capita on health than the European Union average, although public expenditure has been growing steadily, with an increasing role of government budget transfers towards the social health insurance model. Despite these efforts, more than a fifth of current health expenditure comes from out-of-pocket payments, creating pressure to develop new and strengthen existing financial protection instruments. Life expectancy in Estonia has increased rapidly over the past decade, but not fast enough to meet the targets set in strategic documents. The first years of the COVID-19 pandemic were marked by a decline in life expectancy and high excess mortality, which set back progress. Despite this, Estonia's gains in population health were more pronounced in 2022. Overall, health inequalities between socioeconomic groups remain high, prompting policymakers to take steps to increase equity in access to care. The outstanding challenges for the Estonian health system include: addressing the shortage of primary and mental health experts, especially given the growing burden of chronic conditions and other needs of the ageing population; minimizing stark socioeconomic inequalities in health outcomes; renewing the outdated public health framework; and further improving integration and coordination of care and clinical decision-making.

The ecosystem of health decision making: from fragmentation to synergy.

Clinicians, patients, policy makers, funders, programme managers, regulators, and science communities invest considerable amounts of time and energy in influencing or making decisions at various levels, using systematic reviews, health technology assessments, guideline recommendations, coverage decisions, selection of essential medicines and diagnostics, quality assurance and improvement schemes, and policy and evidence briefs. The criteria and methods that these actors use in their work differ (eg, the role economic analysis has in decision making), but these methods frequently overlap and exist together. Under the aegis of WHO, we have brought together representatives of different areas to reconcile how the evidence that influences decisions is used across multiple health system decision levels. We describe the overlap and differences in decision-making criteria between different actors in the health sector to provide bridging opportunities through a unifying broad framework that we call theory of everything. Although decision-making activities respond to system needs, processes are often poorly coordinated, both globally and on a country level. A decision made in isolation from other decisions on the same topic could cause misleading, unnecessary, or conflicted inputs to the health system and, therefore, confusion and resource waste.

Estonia advances on SDG achievement by tackling high alcohol consumption through a multi-pronged approach.

Estonia has implemented a comprehensive, multipronged approach to the reduction of alcohol consumption in the population, comprising a series of successful policy responses. The Estonian alcohol strategy (2014) builds on the Global strategy to reduce the harmful use of alcohol and the European action plan to reduce the harmful use of alcohol 2012-2010. It aims to decrease the overall yearly consumption of alcohol among the adult population to less than 8 litres of absolute alcohol per capita. Gathering support across society from a range of stakeholders, including policy-makers, researchers, parents and advocates, has been one of the key elements in the implementation of the policy. High-level political commitment and strategic timing of efforts have maintained the issue of alcohol control on the political agenda and in the public's mind.

Participatory approaches to reaching the Sustainable Development Goals: Estonia: a multipronged alcohol policy involving all levels of society

Estonia has implemented a comprehensive, multipronged approach to the reduction of alcohol consumption in the population, comprising a series of successful policy responses. The Estonian alcohol strategy, adopted in 2014, builds on the “Global strategy to reduce the harmful use of alcohol” and the “European action plan to reduce the harmful use of alcohol 2012–2010”. It aims to decrease the overall yearly consumption of alcohol among the adult population to less than 8 litres of absolute alcohol per capita. Gathering support across society from a range of stakeholders, including policy-makers, researchers, parents and advocates, has been one of the key elements in the implementation of the policy.