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At the WHO Conference „Health Systems for Prosperity and Solidarity: leaving no one behind"


First of all, it is a privilege to celebrate jointly with you the centennial anniversary of the Estonian Republic this year and also the 10 year anniversary of the Tallinn Charter.

In 2008, 53 countries signed the Tallinn Charter: Health Systems for Health and Wealth. The underlying values in the charter were solidarity, equity and universalism.

Already at that time, the Charter was extremely broad raising the philosophy, which is now deeply rooted in the European societies, that health is a fundamental right of all people.

The Charter described that people´s well-being is at the centre of the triangle of strong and resilient health systems, health and wealth. It is needless to state, that at this time, these values were forward-looking.

Universal health coverage is one thing that makes it tolerable to have income inequality in societies because people know that one of their basic needs is covered. As you may know here in Estonia we have a single payer scheme where patients do not pay. We are very proud of it and we believe that we have a system that is also efficient and effective at the same time inclusive. These are the principles that were raised also in Tallinn Charter. It would be very sad if we arrived here in year 2018 and we would have to say that even if it is the Tallinn Charter we do not respect it. We do, I can assure you.

The Charter did describe that people's wellbeing is at the center of the triangle of a strong and resilient health systems – health and wealth. Of course at that time these values were quite forward looking and world did not yet resemble too much what the Tallinn Charter was stating. I feel it is still relevant today. It does address major health challenges ahead. We have demographic change, widening socioeconomic disparities everywhere, limited resources, technological development which makes of course treatment more expensive and people´s rising expectations towards healthcare systems.

Economic outlooks predict increasing inequalities in income and this does put pressure on everybody's health and social budgets.

To manage these challenges, it is important to understand that health systems involve more than health care, because they need to promote, remember – both health and wealth.

Investment in health is an investment in future human development and well-functioning health systems are so essential to improve societies' health in general. We acknowledge that good health adds value to the human resources we have, it creates a solid ground for the development and innovation in other sectors. For small countries like Estonia with 1,3 million people, here every person and their input to the society really counts.

We have been able to use previous difficult and economically very demanding periods to make hard decisions. It does enable us to use the favourable care, what we are right now enjoying, for development. After regaining our independence the income level in Estonia was very low – about 30 dollars per person per month. It's now close to 1300 euros. It's a huge gain in wealth which has allowed us to develop our health care. Of course it has been very important that we do so efficiently and effectively. That we don't add unnecessary bureaucracy to the system that we don't make the system more complicated just because we have more resources. This has always been a challenge, but I do believe that we have managed.

We have also been helped very much by our e-services development in this country. I would also like to mention our biggest pride and joy – the commonly shared service of e-prescription between Estonia and Finland. This is two countries who recognise each other's e-prescriptions. We have had e-prescription system here quite long already. It was very difficult to start it because of course particularly elderly people were so used to walking out from the doctor's office with a prescription in their hands. Originally it wasn't so easy also technically to make the system function. I think it was one of the hardest deployment of e-service in Estonia originally, but we managed. Now Estonians and Finns share it. There are lot of other services in pipeline which we could share with our partners in Finland because we operate on the same platform – the X-road platform. And we are also ready to cooperate on that platform with other countries. But this is currently our pride and joy – an international cooperation in e-health.

We also have a e-health system, where the data about our patients is logged. We dream here, that whatever happens to me wherever I fall off my feet there will be an ambulance coming and they will see all my medical history immediately. They will see quite a big proportion it already now but I don't think it is quite holistic, quite conclusive now. We need to work on it and we are working on it. This is our objective and our aim. It saves a lot of time for the patients and also a lot of resources for the healthcare, because we know very well that if we go to the doctor in a country were medical systems are not connected, quite often for business reasons, because doctors want to keep their income then we face different analyses several times. It is time consuming, but also very wasteful. I think we all have these experiences. In an e-health system this problem disappears and you even out yet again some inequalities.

Nowadays we expect healthcare not only to cover our illnesses, we also expect our healthcare to take care of us preventively. We need ex-ante care. You may know that in Estonia already since the turn of the century operates Estonian Geno Foundation. We started it when Iceland started it by creating a legally permissive environment for this kind of population level genetic analyses. Like in all other Estonian e-services this is not a wild west were everything is permitted. Quite to the contrary – this is closely and clearly regulated environment which means that people are safe to give their blood to be analysed for common markers of hereditary diseases. The doctors know how to handle it and scientists who are able to use this data to – in a non-personalised format of course – they know which are the rules based on which they use. When we created the system, non-specialists found it very hard to understand that this closely regulated environment is exactly which brings in a lot of private money to the sector and it did initially. Later on I have to say that the last decade has shown that since most governments were ready to pay for what we got from private sector for free, they ruined the market and we faced some difficulties in developing the project. But yet, it couldn't happen in Estonian Geno Foundation and our gene legal base what we have witnessed for example in case of digital services like Facebook, having to go around the world and apologising for the crimes it did not commit because there is no law space anyway. There was no law against those things they did and are now accused for. That shows to everybody now how important it is to regulate, both the e-health environment and of course the Estonian gene environment. The aim is that everybody is safe – patients are safe, doctors are safe and those who use this data are safe as well.

We now look that in the next couple of years enough of Estonians donate their blood to be analysed to receive the information about the most common hereditary markers which will be on their doctors file so that their doctor can advise them. If we can reach 10 percent of the population with this kind of system it makes the primary healthcare much more preventive, much more ex-ante. Not only for this 10 percent who have their genes analysed but for much bigger amount of people because they all have relatives as we know and we share the genes. So the risks will also be apparent for the whole families.

The price of this kind of analyses has fallen now to tolerable level and can be done also through public healthcare. It wasn't originally, but since we were able to look forward and see the developments in the technology and the government was also ready to take some risks, we now have this which I believe not many countries can say they have, at least not to this level population coverage as Estonians do.

As I already said for us it is very important that the out-of-pocket cost for people are low in our healthcare model. And this is also the biggest tension in our healthcare system which I feel. We have excluded some services which is quite common – dental services for example, people have to pay for medicaments. But I'm quite sure we also have a system in the place which compensates for more weak and more vulnerable parts of the society which helps people to participate in our healthcare system.

I don't know how many of you know, but Estonia spends 6.7% of GDP on health, which is much less than EU or OECD average. It is very hard of course to measure what we get for it because also minister is day in and day out facing difficult choices. We have chosen an inclusive cover for people, fully recognising that this means that some treatments, the peak-cost treatments, also new and experimental like some cancer treatments, that they may be out of the reach of our citizens. We have been honest and communicating. Therefore society has taken and also the ministry has taken mitigating risks to help those patients as well. How has society taken mitigating risks is that there is a foundation. It doesn't command that much money, only 1 percent of the cancer treatment money that state is spending, is added by this private foundation. Yet it does cover those patients who have received a no from the healthcare system, because the treatment is experimental. So this is the societies' side of mitigating the risk of not being treated. Also the ministry can do something, for example since we have the geno foundation we have been able to capture some capture some attention of the big pharma companies to analyse whether they can support cancer treatment in exchange of the genetic data of these families where these cancers exist.

So you see, we have made a conscious decision that everybody is covered, we have communicated to the society the risks of this kind of system meaning that the peaks are cut off for everybody and the society itself, the third sector and also the ministry of social affairs try to mitigate these risks. We believe that this way we are actually able to help our people to the maximum level considering also, that although we are now considered a high-income country – we are 36th globally as far as wealth is concerned – we still do not belong to those ranked top. Of course our people and people as everywhere are very demanding, they would all like to have a tax level which is relatively low and service level, which is extremely high. But it's a good thing because that thrives us to most positive developments.

I think we have lived up to the values described by the Tallinn Charter and we continue to live by those values and develop those values as best we can and efficiently.