Estonia: Health System Summary, 2024

This Health System Summary is based on the Estonia: Health System Review published in 2023 in the Health Systems in Transition (HiT) series. Health System Summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

Methods and tools to assess implementation of mental health policies and plans: A systematic review.

Mental health policies and plans (MHPPs) are important policy instruments and powerful tools to facilitate development of mental health systems and services across the world. We aimed to map and analyse methods and tools used to assess the extent, process and impact of implementing MHPPs. We systematically searched peer-reviewed and grey literature across seven scientific databases. We extracted and analysed the data on a) the characteristics of included studies (e.g., policy areas, region of origin, income setting) and b) the methodology and evaluation tools applied to assess the extent and process of implementation. We included 48 studies in the analyses. Twenty-six of these studies employed only qualitative methods (e.g., semi-structured interviews, focus group discussions, desk review, stakeholder consultations); 12 studies used quantitative methods (e.g., trend analysis, survey) and 10 used mixed-methods approaches. Generally, methods and tools used for assessment were described poorly with less than half of the studies providing partial or full details about them. Only three studies provided assessment of full policies. There is a lack of rigorous research to assess implementation MHPPs. Assessments of the implementation of entire MHPPs are almost non-existent. Strategies to assess the implementation of MHPPs should be an integral part of MHPPs.

An ethical analysis of policy dialogues.

BACKGROUND: A policy dialogue is a tool which promotes evidence-informed policy-making. It involves deliberation about a high-priority issue, informed by a synthesis of the best-available evidence, where potential policy interventions are discussed by stakeholders. We offer an ethical analysis of policy dialogues - an argument about how policy dialogues ought to be conceived and executed - to guide those organizing and participating in policy dialogues. Our analysis focuses on the deliberative dialogues themselves, rather than ethical issues in the broader policy context within which they are situated. METHODS: We conduct a philosophical conceptual analysis of policy dialogues, informed by a formal and an interpretative literature review. RESULTS: We identify the objectives of policy dialogues, and consider the procedural and substantive values that should govern them. As knowledge translation tools, the chief objective of policy dialogues is to ensure that prospective evidence-informed health policies are appropriate for and likely to support evidence-informed decision-making in a particular context. We identify five core characteristics which serve this objective: policy dialogues are (i) focused on a high-priority issue, (ii) evidence-informed, (iii) deliberative, (iv) participatory and (v) action-oriented. In contrast to dominant ethical frameworks for policy-making, we argue that transparency and accountability are not central procedural values for policy dialogues, as they are liable to inhibit the open deliberation that is necessary for successful policy dialogues. Instead, policy dialogues are legitimate insofar as they pursue the objectives and embody the core characteristics identified above. Finally, we argue that good policy dialogues need to actively consider a range of substantive values other than health benefit and equity. CONCLUSIONS: Policy dialogues should recognize the limits of effectiveness as a guiding value for policy-making, and operate with an expansive conception of successful outcomes. We offer a set of questions to support those organizing and participating in policy dialogues.

National policies for delivering tuberculosis, HIV and hepatitis B and C virus infection services for refugees and migrants among Member States of the WHO European Region.

BACKGROUND/OBJECTIVE: Refugees and migrants to the World Health Organization (WHO) European Region are disproportionately affected by infections, including tuberculosis (TB), human immunodeficiency virus (HIV) and hepatitis B and C (HBV/HCV) compared with the host population. There are inequities in the accessibility and quality of health services available to refugees and migrants in the Region. This has consequences for health outcomes and will ultimately impact the ability to meet Regional infection elimination targets. METHODS: We reviewed academic and grey literature to identify national policies and guidelines for TB/HIV/HBV/HCV specific to refugees and migrants in the Member States of the WHO European Region and to identify: (i) evidence informing policy and (ii) barriers and facilitators to policy implementation. RESULTS: Relatively few primary national policy/guideline documents were identified which related to refugees and migrants and TB [14 of 53 Member States (26%), HIV (n = 15, 28%) and HBV/HCV (n = 3, 6%)], which often did not align with the WHO recommendations, and for some countries, violated refugees' and migrants' human rights. We found extreme heterogeneity in the implementation of the WHO- and European Centre for Disease Prevention and Control (ECDC)-advocated policies and recommendations on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection among migrants across the Member States of the WHO European Region.There is great heterogeneity in implementation of WHO- and ECDC-advocated policies on the prevention, diagnosis, treatment and care of TB/HIV/HBV/HCV infection in refugees and migrants across the Member States in the Region. CONCLUSION: More transparent and accessible reporting of national policies and guidelines are required, together with the evidence base upon which these policy decisions are based. Political engagement is essential to drive the changes in national legislation to ensure equitable and universal access to the diagnosis and care for infectious diseases.

Estonia: health system summary, 2022

This Health system summary is based on the Estonia: Health System Review published in 2018 in the Health Systems in Transition (HiT) series, and is significantly updated, including data, policy developments and relevant reforms as highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 unless otherwise stated. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system.

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.

An evaluation of the evidence brief for policy development process in WHO EVIPNet Europe countries.

BACKGROUND: Evidence briefs for policy (EBPs) represent a potentially powerful tool for supporting evidence-informed policy-making. Since 2012, WHO Evidence-Informed Policy Network (EVIPNet) Europe has been supporting Member States in developing EBPs. The aim of this study was to evaluate the process of developing EBPs in Estonia, Hungary and Slovenia. METHODS: We used a rapid appraisal approach, combining semi-structured interviews and document review, guided by the Medical Research Council (MRC) process evaluation framework. Interviews were conducted with a total of 20 individuals familiar with the EBP process in the three study countries. Data were analysed thematically, and emerging themes were related back to the MRC framework components (implementation, mechanisms of impact, and context). We also reflected on the appropriateness of this evaluation approach for EVIPNet teams without evaluation research expertise to conduct themselves. RESULTS: The following themes emerged as important to the EBP development process: how the focus problem is prioritized, who initiates this process, EBP team composition, EBP team leadership, availability of external support in the process, and the culture of policy-making in a country. In particular, the EBP process seemed to be supported by early engagement of the Ministry of Health and other stakeholders as initiators, clear EBP team roles and expectations, including a strong leader, external support to strengthen EBP team capacity and cultural acceptance of the necessity of evidence-informed policy-making. Overall, the evaluation approach was considered feasible by the EBP teams and captured rich qualitative data, but may be limited by the absence of external reviewers and long lag times between the EBP process and the evaluation. CONCLUSIONS: This process occurs in a complex system and must be conceptualized in each country and each EBP project in a way that fits local policy-making culture, priorities, leadership and team styles, roles and available resources. The use of a rapid appraisal approach, combining qualitative interviews and document review, is a feasible method of process evaluation for EVIPNet member countries.

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.

Lessons learned from the Baltic countries' response to the first wave of COVID-19.

The Baltic countries of Estonia, Latvia, and Lithuania shared a similar response to the first wave of the COVID-19 pandemic. Using the information available on the COVID-19 Health System Response Monitor platform, this article analyzed measures taken to prevent transmission, ensure capacity, provide essential services, finance the health system, and coordinate their governance approaches. All three countries used a highly centralized approach and implemented restrictive measures relatively early, with a state of emergency declared with fewer than 30 reported cases in each country. Due to initially low COVID-19 incidence, the countries built up their capacities for testing, contact tracing, and infrastructure, without a major stress test to the health system throughout the spring and summer of 2020, yet issues with accessing routine health care services had already started manifesting themselves. The countries in the Baltic region entered the pandemic with a precarious starting point, particularly due to smaller operational budgets and health workforce shortages, which may have contributed to their escalated response aiming to prevent transmission during the first wave. Subsequent waves, however, were much more damaging. This article focuses on early responses to the pandemic in the Baltic states highlighting measures taken to prevent virus transmission in the face of major uncertainties.

A comprehensive monitoring and evaluation framework for evidence to policy networks.

OBJECTIVE: To describe the development of a framework for monitoring and evaluating knowledge translation (KT) networks. METHOD: The framework was developed using mixed methods over four phases, including i) a targeted literature review of KT networks, activities and indicators, ii) two scoping reviews to further enhance the set of indicators, iii) peer-reviews by international KT experts and an online expert consultation, and iv) piloting. RESULTS: A comprehensive theory of change (ToC) and indicators, both for the Network Secretariat and its participating member countries, were identified to develop the monitoring and evaluation framework. The framework includes (i) a ToC, including three key indicator domains across the results chain (outputs, short term outcomes, intermediate outcomes), and (ii) indicators for the three key domains, that can be selected depending on the stage of network maturity, along with suggested data collection methods. The three key indicator domains are 1) KT capacity and skill building; 2) network (structure, governance and leadership); and 3) KT/evidence-informed policy value and culture. CONCLUSION: The monitoring and evaluation framework that links KT activities with policy and health outcomes fills an important gap in optimizing KT procedures, generating lessons learned and increasing accountability of major multipartner KT networks.

Integrating citizen engagement into evidence-informed health policy-making in eastern Europe and central Asia: scoping study and future research priorities.

BACKGROUND: The perspectives of citizens are an important and often overlooked source of evidence for informing health policy. Despite growing encouragement for its adoption, little is known regarding how citizen engagement may be integrated into evidence-informed health policy-making in low- and middle-income counties (LMICs) and newly democratic states (NDSs). We aimed to identify the factors and variables affecting the potential integration of citizen engagement into evidence-informed health policy-making in LMICs and NDSs and understand whether its implementation may require a different approach outside of high-income western democracies. Further, we assessed the context-specific considerations for the practical implementation of citizen engagement in one focus region-eastern Europe and central Asia. METHODS: First, adopting a scoping review methodology, we conducted and updated searches of six electronic databases, as well as a comprehensive grey literature search, on citizen engagement in LMICs and NDSs, published before December 2019. We extracted insights about the approaches to citizen engagement, as well as implementation considerations (facilitators and barriers) and additional political factors, in developing an analysis framework. Second, we undertook exploratory methods to identify relevant literature on the socio-political environment of the focus region, before subjecting these sources to the same analysis framework. RESULTS: Our searches identified 479 unique sources, of which 28 were adjudged to be relevant. The effective integration of citizen engagement within policy-making processes in LMICs and NDSs was found to be predominantly dependent upon the willingness and capacity of citizens and policy-makers. In the focus region, the implementation of citizen engagement within evidence-informed health policy-making is constrained by a lack of mutual trust between citizens and policy-makers. This is exacerbated by inadequate incentives and capacity for either side to engage. CONCLUSIONS: This research found no reason why citizen engagement could not adopt the same form in LMICs and NDSs as it does in high-income western democracies. However, it is recognized that certain political contexts may require additional support in developing and implementing citizen engagement, such as through trialling mechanisms at subnational scales. While specifically outlining the potential for citizen engagement, this study highlights the need for further research on its practical implementation.

Emerging electronic cigarette policies in European member states, Canada, and the United States.

BACKGROUND: Increased electronic cigarette (ECIG) use has motivated new regulations to address the changing landscape of tobacco use and promote public health. METHOD: This policy scan compares ECIG prevalence and regulations in the European Union (EU), Canada, and the United States (US) at the federal- and local-level to foster a policy dialogue around modern tobacco prevention and control regulations. RESULTS: Among young adults, 40 % in the US, 29 % in Canada, and 28 % in the EU report ever using an ECIG. Results from the policy scan find significant variation in approach to regulating ECIGs. EU member states are subject to the most stringent requirements regarding nicotine concentration regulations, and several member states have also opted to ban flavors and/or require plain packaging or out of sight retail sales. Among EU and US states, taxation is a popular strategy, though taxing strategies vary widely. Regarding youth use, US states have led the way for increasing the legal age of sale to 21 at the federal level, and in Canada recent federal regulations are innovative in their approach to banning advertising that may appeal to youth. CONCLUSION: Strategies to achieve public health goals related to ECIGs vary widely, with federalism playing an important role in policy innovation, offering opportunities to evaluate their effectiveness and inform future regulations.

Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19: A Living Systematic Review of Multiple Streams of Evidence.

BACKGROUND: Mechanical ventilation is used to treat respiratory failure in coronavirus disease 2019 (COVID-19). PURPOSE: To review multiple streams of evidence regarding the benefits and harms of ventilation techniques for coronavirus infections, including that causing COVID-19. DATA SOURCES: 21 standard, World Health Organization-specific and COVID-19-specific databases, without language restrictions, until 1 May 2020. STUDY SELECTION: Studies of any design and language comparing different oxygenation approaches in patients with coronavirus infections, including severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS), or with hypoxemic respiratory failure. Animal, mechanistic, laboratory, and preclinical evidence was gathered regarding aerosol dispersion of coronavirus. Studies evaluating risk for virus transmission to health care workers from aerosol-generating procedures (AGPs) were included. DATA EXTRACTION: Independent and duplicate screening, data abstraction, and risk-of-bias assessment (GRADE for certainty of evidence and AMSTAR 2 for included systematic reviews). DATA SYNTHESIS: 123 studies were eligible (45 on COVID-19, 70 on SARS, 8 on MERS), but only 5 studies (1 on COVID-19, 3 on SARS, 1 on MERS) adjusted for important confounders. A study in hospitalized patients with COVID-19 reported slightly higher mortality with noninvasive ventilation (NIV) than with invasive mechanical ventilation (IMV), but 2 opposing studies, 1 in patients with MERS and 1 in patients with SARS, suggest a reduction in mortality with NIV (very-low-certainty evidence). Two studies in patients with SARS report a reduction in mortality with NIV compared with no mechanical ventilation (low-certainty evidence). Two systematic reviews suggest a large reduction in mortality with NIV compared with conventional oxygen therapy. Other included studies suggest increased odds of transmission from AGPs. LIMITATION: Direct studies in COVID-19 are limited and poorly reported. CONCLUSION: Indirect and low-certainty evidence suggests that use of NIV, similar to IMV, probably reduces mortality but may increase the risk for transmission of COVID-19 to health care workers. PRIMARY FUNDING SOURCE: World Health Organization. (PROSPERO: CRD42020178187).