Audit finds Estonia’s health reforms outpace its capacity to deliver

Estonia has not improved access to specialist care despite sharply higher health spending, while shortages of family doctors are growing and planned reforms exceed available funding, staff and IT capacity, the National Audit Office says in a new report published by ERR.

Many problems identified in the office’s 2022 annual report and later audits remain unresolved, including uncertainty over long-term health funding, shortages of health workers, an organisation of care that does not match changing needs and delays in making necessary decisions. The report also notes progress in children’s health checks, use of e-consultations, family medicine work arrangements and the renewal of the system for assessing treatment quality.

Health spending rose by about 61 percent between 2020 and 2025, reaching more than 3.3 billion euros last year. About 2.5 billion euros came from public funding. The increase reflected more frequent use of services, more complex treatment and general price rises.

Governments have repeatedly promised to find a long-term funding solution, but decisions have not been made, the audit office said. Temporary measures and planned savings may cover shortfalls in the coming years, but do not answer how much funding health care will need in the longer term or where it should come from as the population ages and demand for treatment grows. The report says those choices must be made by the government and parliament.

Patients paid 21 percent of health costs out of pocket in 2024, compared with an EU average of 15 percent in 2023. The maximum permitted wait for an outpatient specialist appointment is 42 days, but in March the median wait exceeded that limit in many specialties and at several care providers. More than 10,500 first-appointment bookings had waits of over 60 days, and more than a third of those patients faced waits exceeding 90 days. At some providers, waits for an ophthalmologist or ophthalmology nurse reached 126 to 208 days, while waits for an endocrinologist or cardiologist exceeded 110 days. Actual waits can be longer because patients sometimes cannot book an appointment when no slots are available.

More people lack a permanent family doctor

The number of people on lists without a permanent family doctor has risen from about 72,500 in 2022 to nearly 110,700. The average age of family doctors is increasing, and more than half of doctors with patient lists are at least 60 years old.

The audit office said the Ministry of Social Affairs should develop a model for family medicine that accounts for long-term workforce shortages and makes clear to patients where they can get help and who is responsible for continuity of their care.

Training more doctors and nurses alone will not solve workforce shortages, the report said. Retaining current staff and making better use of their skills are also important. The number of health workers and training volumes have increased since 2022, but shortages have not eased significantly, and overtime remains high and has risen since 2020.

The report concludes that the abundance of development plans and reforms has not produced a comparable number of solutions because the ambitions exceed the system’s capacity to implement them.