5.1. Public health

5.1.1. Public health governance

Since 2008, when the first NHP 2009–2020 was approved by the Estonian Government, public health has become an integrated part of the health system with common goals for the whole health sector. In April 2021, the Estonian Government adopted the NHP 2020–2030, setting common goals for the current decade. The NHP stresses the importance of evidence-based health policy and states the main principles in implementation of the plan to achieve the objectives. These principles include, for example, health-for-all policies, cooperation, reduction of health inequalities, innovative approaches and involvement of communities. The NHP is being implemented through three main programmes: healthy choices, health-supportive environment and person-centred health care.

Public health in Estonia is a decentralized multi-stakeholder system. Its activities address the main health risks, including preventable ones, related to lifestyle choices (including use of alcohol, nicotine and narcotics, unbalanced diet, physical inactivity, sexual and reproductive health, prevention of communicable diseases). It also covers activities to enhance positive impact on health and minimize health risks from the living environment, focusing on factors such as climate change, planning, construction and usage of buildings, chemical safety, noise, drinking-water, electromagnetic fields, ultraviolet radiation and chemicals in various types of products.

The Public Health Act provides the main legal frame regulation in public health, defining roles, responsibilities, requirements and tools. However, the plans to introduce a new Public Health Act, which would modernize the principles of public health and clarify the fragmented roles and responsibilities of national, regional and local counterparts, have been delayed. The Estonian Government approved the new Public Health Act in November 2021, but it has not been adopted by the parliament because of amendments submitted by two opposition parties. The main obstacle was the regulation of gender correction, which is considered in the current legislation as a health care service and should not be regulated under the Public Health Act. The Estonian Government that was formed in April 2023 included the adoption of the new Public Health Act to its work programme for 2023–2027 with the aim of discussing it and giving government approval in November 2023 (see section 6.2 Future developments).

The MoSA is the main governing body in the field of public health and is responsible for strategic planning and, on this basis, for shaping the legislative framework. Other key national actors in public health are the Health Board, the NIHD, the EHIF, the SAM and the Labour Inspectorate, although other ministries and authorities in their administrative area have responsibility for wider, not directly health-related, fields, where evidence-based interventions should be taken to improve the health of the population (for example, marketing, taxation) (see section 2.2.1 The role of the state and its agencies).

In 2021, the Minister of Education and Research, the Minister of Justice, the Minister of Culture, the Minister of Finance, the Minister of Social Protection, the Minister of the Interior and the Minister of Health and Labour signed an agreement on the principles of universal multisectoral prevention in order to coordinate and improve the quality of the prevention activities of the various parties.

At the end of 2022, a cross-sectoral Prevention Council was established to advise the Estonian Government on prevention, crime, drugs and child protection policies. The main objective of the council is to create a common basis for the development of interdisciplinary prevention strategies. It also aims to create an action plan to facilitate cooperation between different fields, to formulate policies on drugs, crime and child protection and to set strategic goals. The council is chaired by the Minister of Justice and the vice-chairmen are the Ministers of Education and Research, Culture, Social Protection and Health. The Prevention Council is supported by a working group of officials and specialists.

In 2021, the NIHD established a Prevention Research Council with several tasks: (1) to agree on standardized public health terminology; (2) to develop a manual for advising and evaluating the effectiveness of prevention interventions and programmes; (3) to establish an annual plan for the evaluation of interventions; (4) to designate evaluators for each intervention; (5) to define a ranking system for evidence-based effectiveness. By the summer of 2023, the Council had evaluated 10 interventions, six of which received a ranking based on their evidence-based effectiveness.

From 1996 to 2018, county governments coordinated public health at the regional level. Each county government employed a health promotion specialist or distributed the tasks between different persons and formed a county health council, which acted as a link between the national and municipal levels and coordinated county-specific health promotion efforts. In 2018, as a result of the public administration reform, the number of local municipalities was reduced from 213 to 79, the institution of county governments was abolished and several formerly regional tasks were transferred to the local municipalities. According to the Public Health Act, all municipalities in Estonia are required to monitor adherence to and implementation of health protection legislation in their territory. They must also coordinate local health promotion and disease prevention activities (see section 2.2.2 Local governments).

The Public Health Act requires local municipalities to work together to create a healthy and safe living environment. This includes jointly compiling health and well-being profiles, shaping health promotion and disease prevention policies, implementing activities and organizing local networking. To execute these duties, the municipalities have established County Development Organizations, which form councils responsible for public health and safety. In addition, all counties and bigger towns (such as Tallinn and Tartu) have one or more health promotion specialists. The NIHD supports this work by counselling, advising and training municipal personnel and the health promotion specialists.

At the state level, the Safety Council Steering Group brings together representatives of municipalities, council representatives and representatives of the Ministry of Justice, the Ministry of the Interior, the MoSA, the Ministry of Finance, the NIHD, Social Insurance Board, Estonian Police and Border Guard Board, and Estonian Rescue Board. The main aim of the Safety Council Steering Group is to improve collaboration and coordination between local and state levels.

All 15 counties have developed health and well-being profiles, some of which need to be updated, as they are supposed to be revised every four years. According to the results of the recent study, the majority of local leaders agree that health impact and safety should be considered in strategic planning across all sectors. Furthermore, they understand that municipalities play a key role in shaping public health at the local level. However, in practice, the core principle “health-for-all policies” is rarely implemented at the local level due to a lack of willingness to allocate more funding to public health and safety (Purru & Seema, 2021) (see sections 2.2.2 Local governments and 2.5 Intersectorality).

5.1.2. Surveillance of population health and well-being

Since 1990, Estonia has been conducting several biennial and quadrennial surveys on adult and child health and behaviour. These include the Estonian Adult Population Health Behaviour Study (latest data collected in 2022), Estonian Health Interview Survey (2019) and Survey of Health, Ageing and Retirement (SHARE 2022). From 2015 to 2018 and onwards, surveys of Drug Use by the Estonian Adult Population and Sexual Behaviour among Estonian Adult Population, and nutrition surveys have been carried out. Furthermore, with the focus on child and adolescent health, the following studies take place each four years: Health Behaviour in School-Aged Children, European School Survey Project on Alcohol and Other Drugs, and Childhood Obesity Surveillance Initiative (COSI). Most of the data are published by the NIHD in the national health statistics and health research database (NIHD, 2023e). However, the collection and analysis of data are time-consuming and results are often underutilized in health policy discussions and conclusions (see section 2.6 Health information systems).

5.1.3. Disease prevention, health protection and promotion

Communicable disease prevention

The MoSA (Department of Public Health and Department of Health System Development), the Health Board, the NIHD and the EHIF have key responsibilities for the prevention and control of communicable diseases. The scope and roles are defined in the Communicable Diseases Prevention and Control Act (2003), the Public Health Act (1995) and several other legislative documents. Although the ministry has responsibility for strategic planning and legislation, the Health Board acts as the competent authority of communicable diseases and organizes the surveillance of communicable diseases. The Health Board is responsible for planning and implementing activities regarding communicable disease prevention, except for TB and HIV. The Health Board is responsible for monitoring the incidence and prevalence of HIV and TB. The NIHD is responsible for the implementation of TB and HIV disease prevention and harm reduction activities and the organization of related health services, the publication of epidemiological data on HIV and TB, and the management of the TB Registry. The HIV prevention, treatment and counselling activities are planned in the NHP and in the National Action Plan for HIV 2017–2025, funded from the state budget. They include services for injecting drug users, voluntary HIV testing, counselling services for at-risk population groups and the general population, and directly observed treatment for TB. The EHIF procures antiretroviral and anti-TB drugs centrally and distributes them to health care providers for free dispensing to patients with TB or HIV/AIDS.

Communicable disease surveillance is built around the Communicable Disease Information System, which requires health care providers and laboratories to report 56 communicable diseases and 97 etiological agents. These data are stored nationally in the Estonian Communicable Diseases Registry, effective since October 2009. The electronic system has reduced the time lag in reporting, as the proportion of paper-based reporting is gradually decreasing (in 2019, 87.4% of all notifications were reported electronically) (see section 2.6 Health information systems).

Estonia mandates countrywide reporting of communicable disease outbreaks. The suspected outbreaks must be reported immediately to the Health Board, which follows up with an investigation and conducts a report (including foodborne disease with the Agriculture and Food Board). Regional departments of the Health Board are responsible for the detection and investigation of outbreaks, using epidemiological investigations, laboratory diagnostics and, if necessary, legal action. Persons infected with an extremely dangerous communicable disease may be eligible for involuntary hospital treatment if they pose a risk to others or have violated their treatment regimen (even without a court ruling if necessary for public or personal protection) (see sections 2.2.1 The role of the state and its agencies and 2.6 Health information systems).

In addition, hospitals are responsible for collecting information on health care-associated infections and antimicrobial-resistant infections by employing a doctor or nurse responsible for the prevention and control of infectious diseases. They are also responsible for ensuring that the necessary guidelines and training are in place and implemented. The Health Board establishes the national guidelines and surveillance system for health care-associated infections and the control of antimicrobial resistance.

The Communicable Diseases Prevention and Control Act provides the general legal framework for immunization. The MoSA of Estonia, supported by the national expert committee of immunoprophylaxis, coordinates the vaccination strategy and the national immunization schedule. The EHIF is responsible for the procurement of vaccines for the national immunization schedule (see section 2.7.4 Regulation and governance of pharmaceuticals). The Health Board monitors the immunization coverage and assesses the risks involved and acts as the competent authority regarding immunization.

The Emergency Act, adopted in 2009, provides a framework for the organization of emergency preparedness and response. The Health Board has prepared contingency plans for large-scale poisonings and epidemics and acts as a focal point for the International Health Regulations (2005). From 2021, the Government Office has led the process of drafting a new act on crisis preparedness, which will integrate the current Emergency Act, National Defence Act and State of Emergency Act. In addition, the MoSA of Estonia is working on a preparedness plan for epidemics. During the COVID-19 pandemic in 2020, the Estonian Government, after declaring the state of emergency, took a leading role in managing the pandemic response. It also formed a temporary scientific council to provide independent scientific advice to the government. The Government Office coordinated the work between different ministries. All ministries were involved in developing various restrictions to control the spread of the disease, if these restrictions affected their responsibilities, and special regular working groups were set up to improve information exchange and coordination of work (see section 6.1.9 Building health sector capacity in emergency preparedness and response).

Noncommunicable disease prevention

The Department of Public Health of the MoSA is responsible for strategic planning and regulation in the field of prevention of noncommunicable diseases. The NIHD is in charge of supporting evidence-based policy-making, developing evidence-based programmes and services to implement the policy, monitoring and analysing target groups and populations, and raising awareness and skills among different target groups.

The EHIF’s role in noncommunicable disease prevention is mainly limited to the financing of PHC services, particularly testing, screening and counselling. The PHC QBS covers check-ups for children by family physicians, and check-ups and counselling for certain adult risk groups (people aged 40–60 years with hypertension or diabetes) by a family nurse. Part of the EHIF budget is specifically dedicated to national disease prevention projects, such as reproductive health counselling for adolescents; school health services (provided by nurses since 2010) and medical check-ups for young athletes. Some services previously financed through separate programmes are now integrated into a general system, such as neonatal screening for phenylketonuria, hypothyroidism and hearing. The EHIF funds and manages nicotine cessation services and, from 2023, also finances and manages early detection, counselling and treatment of people with alcohol use disorder (see sections 2.2.1 The role of the state and its agencies and 3.3.1 Coverage). Moreover, the EHIF has carried out several campaigns to promote healthy lifestyles.

Since 2014, Estonia has had Green Papers on alcohol and tobacco policy, both of which are comprehensive, evidence-based and have been systematically implemented over the years. In the case of tobacco policy, the Green Paper covers measures to ensure smoke-free environments, reduce the attractiveness of tobacco products, regulate the sale and marketing of new/alternative products containing nicotine, raise awareness, prevent tobacco use, provide counselling for tobacco cessation and treatment, restrict the illicit market and tax tobacco products. A wide range of interventions and measures have been implemented, such as pictorial warnings on tobacco product labels, excise duty increases, flavour and fragrance bans, sales and marketing restrictions, distance selling bans and product displays. However, alternative nicotine products have become widely available and are marketed in ways that appeal to children and adolescents. Recent wastewater studies suggest that nicotine consumption is increasing, at least in some regions of Estonia (Abel-Ollo et al., 2023). In the case of alcohol policy, the Green Paper covers measures such as raising awareness, reducing the availability of alcoholic beverages, pricing and taxation, restrictions on sales promotions, counselling and treatment, and prevention of drink-driving. Despite these efforts, alcohol consumption and deaths directly attributable to alcohol have increased in recent years, probably mainly due to the government’s decision to reduce alcohol excise duty in 2019. However, the Alcohol and Tobacco Policy Green Papers have provided a strong platform for evidence-based, multisectoral and systematic policy-making and implementation, strategically led by the MoSA. The evidence-based data, campaigns, programmes, interventions and service development and piloting have been implemented by the NIHD.

Estonia has had a systematic policy to reduce illicit drug use for many years. The “Drug Control Policy 2030” was adopted in 2021. It is being implemented in cooperation with various ministries (Ministry of the Interior, MoSA, Ministry of Justice, Ministry of Education and Research) and institutions (NIHD, Social Insurance Board, Estonian Police and Border Guard Board, Prosecutor’s Office, Estonian Tax and Customs Board, Medicines Agency, EHIF, Tallinn Welfare and Health Department, Association of Estonian Users of Psychotropic Substances “LUNEST”, Estonian Coalition for Mental Health and Well-being, Association of Estonian Cities and Municipalities). In 2022, the number of drug overdose deaths increased sharply as a result of the appearance of new substances on the market, although several new programmes were implemented to provide support services and counselling for people with drug dependence. From 2022, an anonymous support line (phone and web) has been available to anyone with questions or concerns about substance use. From 2022, nurses can prescribe naloxone, a drug that reverses an opioid overdose.

To address obesity and physical inactivity, a draft for the Green Paper on Nutrition and Physical Activity has been used in Estonia since 2016. The MoSA of Estonia has started to renew the draft and is planning to submit it to the government for adoption in 2024. Various activities have been implemented in this area, such as awareness-raising campaigns on healthy diet, guidelines for foods and meals offered in vending machines and canteens in children’s institutions, a guideline to reduce commercials of unhealthy foods in audio-visual media developed by the Estonian Broadcasting Association, and others. Furthermore, a food reformulation plan to reduce salt, sugar and saturated fat content is under development. Food labelling and safety is under the responsibility of the Ministry of Regional Affairs and Agriculture of Estonia. The Ministry of Culture has announced 2023 as “Be Active” year (Competence Center for Physical Activity, 2023) with the aim to create more interest in society in exercise and healthier lifestyles and thereby increase physical activity.

In addition to the roles mentioned above, the NIHD coordinates the breast, cervical and colorectal cancer screening programmes financed by the EHIF (see section 3.3.1 Coverage). Since January 2015, a cancer screening registry has been launched under the NIHD with the objective of increasing screening effectiveness, coverage and quality. In 2021, the Estonian National Cancer Control Action Plan 2021–2030 was adopted and its implementation is ongoing.

Environmental health

Environmental health is mainly the responsibility of the MoSA (Department of Public Health), the Health Board and the Ministry of Climate (through the Environmental Board) (see section 2.2.1 The role of the state and its agencies).

Water supply, usage, quality and sanitation are regulated by the Public Health Act, the Water Act and the Public Water Supply and Sewerage Act. Water surveillance is divided between different ministries and agencies. The Ministry of Climate is responsible for ensuring and preserving the quality of both ground and surface water (supervisory authority is the Environmental Board). The MoSA is responsible for drinking water quality and bathing water safety regulations (under the supervision of the Health Board).

Responsibilities and measures related to air pollution and noise are regulated by the Atmospheric Air Protection Act. The Environmental Board and the Health Board share responsibility for monitoring the air quality (ambient and indoor air, respectively), while the Health Board has sole responsibility for noise surveillance.

Food safety activities are regulated by the Food Act. Since 2007, the Ministry of Regional Affairs and Agriculture, with its Agriculture and Food Board, has been the lead institution for all major legislation and supervision related to food, including alcohol. Data, investigations and evaluations for risk assessment are provided through various regular monitoring programmes and laboratory analyses by authorized official laboratories.

The Health Board is the competent authority for chemical safety (in the context of REACH (Registration, Evaluation, Authorization and Restriction of Chemicals) regulation, CLP (Classification, Labelling and Packaging) regulation, detergents and biocides) and cosmetic products. The Poisoning Information Centre was established in 2008 and is part of the Health Board; it maintains a database with information on first aid and therapy for each type of poisoning and informs the public. Its telephone hotline has seen a sharp increase in the numbers of calls. In 2010, the hotline received a total of 443 calls, while in 2022 it had 3929 calls.

Occupational health

The Occupational Health and Safety Act (adopted in 1999) sets out responsibilities for occupational health and safety at both state and enterprise levels. Employers are responsible for assessing occupational hazards, preparing a written action plan and notifying their employees about risk factors. The Labour Inspectorate supervises employers’ compliance with these regulations. The occupational health specialist ascertains environmental risk factors in the workplace and gives advice on the working environment. Occupational health doctors carry out medical examinations in the workplace. The Health Board is responsible for the licensing and training of occupational health specialists and is involved in the development and implementation of occupational health programmes.

Since 2008, EU structural funds have been allocated to activities aimed at reducing work-related health risks and promoting health at work (see section 3.6.2 External sources of funds).

Health promotion

Health promotion activities at the national level focus on capacity-building for communities and enhancing evidence-based actions to promote health at local level. The NIHD is responsible for developing a national support system as well as providing counselling and training for health promotion specialists at all levels (counties, municipalities, schools, kindergartens and workplaces). Starting from July 2023, a process has been initiated to move the coordination of the network of health-promoting workplaces to the Labour Inspectorate. The NIHD also disseminates health information to the public and carries out national health campaigns.

Since 1995, the EHIF has been allocating a part of its budget to health promotion activities. The EHIF’s activity in this field is increasing, which is also clearly indicated as a goal in the EHIF action plan for 2022–2025 (see section 7.1.2 Accountability).

The funding of community health promotion at local level has gradually moved from a project-by-project approach to a more strategic planning. However, this system requires further development and capacity-building to ensure evidence-based planning and activities, sustainability, equal capabilities across municipalities, innovation and greater emphasis on addressing health inequities (see section 5.1.1 Public health governance).