PowerPoint Video Module: Medical and Healthcare Innovation in Estonia
Dr. Lorraine Wallace of The Ohio State University College of Medicine and Steven Mousetes, program manager in the College of Medicine, developed this module to give background information on Estonia's history and culture, and the country’s healthcare system.
The PowerPoint video with captions is available on the Center for Slavic and East European Studies’ Youtube channel.
Steven, slide 1: The Ohio State University's Center for Slavic and East European Studies and College of Medicine collaborated to develop this module entitled "Medical and Healthcare Innovation in Estonia." Via Youtube this module is available online for worldwide classroom use. Creation of this module was supported by a U.S. Department of Education Title VI grant to The Ohio State University's Center for Slavic and East European Studies. Information regarding the Ohio State University Center for Slavic and East European Studies is available by visiting the link provided on the lower right corner of this slide.
Steven, slide 2: Greetings from The Ohio State University. Dr. Lorraine Wallace, associate professor, and Steven Mousetes, program manager in the College of Medicine, worked collaboratively to create this module.
Steven, slide 3: In this module, we will provide an overview of Estonia, describe Estonian population health demographics, delineate how the Estonian health care system is structured, explain Estonian personalized medicine initiatives, and provide a listing of additional Estonian health-related resources for further investigation.
Steven, slide 4: Section 1 provides an introduction to the Republic of Estonia, including geographic location and population demographics, overview of Soviet occupation, national flag symbolism, government structure, and diplomatic Estonian and United States missions in both Tallinn and Washington D.C.
Steven, slide 5: The Republic of Estonia is located in northern Europe. Estonia is bordered to the north by the Gulf of Finland, to the west by the Baltic Sea across from Sweden, to the south by Latvia, and to the east by Russia. The territory of Estonia consists of the mainland and over 2,000 islands in the Baltic Sea. With a population of 1.3 million residents, Estonia is one of the least populous countries within the European Union. Note that the population of Franklin County in Ohio is 1.3 million residents. Tallinn, with a population of nearly 450,000 residents, is the largest city and capital of Estonia. While Estonian is the official language, English is widely spoken throughout the country as well. Estonia is a highly developed country. In 2018, their gross domestic product per capita was $23,266.35 in U.S. dollars. This is the economic output per person.
Steven, slide 6: The Union of Soviet Socialist Republics, or USSR, was a federal, socialist state in northern Eurasia that existed from 1922 to 1991. As shown on the map, the Estonia Soviet Socialist Republic, or SSR, was one of 15 states that made up the former USSR. As depicted on the left section of the slide, the Estonian SSR adopted the code of arms in 1940, which remained in place until the dissolution of the USSR. [The code of arms depicts a tree bough on the left, a sheaf of wheat on the right, and a star and hammer and sickle in the middle.]
Steven, slide 7: The tri-color Estonian flag was officially adopted in 1990. The blue represents Estonia's clear skies, freshwater lakes, and the Baltic Sea. The black represents Estonia's fertile soil, while also symbolizing past oppression. The white represents Estonia's winter snow and summery nights, while also symbolizing the struggle for freedom and independence. [The Estonian flag contains blue, black, and white horizontal bars from top to bottom].
Steven, slide 8: Estonia is a democratic, unitary, parliamentary republic. As displayed in the map in the top right corner of the slide, Estonia is divided into 15 counties. In 2005, Estonia became the first nation to hold elections over the internet. Kersti Kaljulaid currently serves as the president of Estonia while Juri Ratas is the prime minister of Estonia. Further information regarding Estonian governance is available by visiting the links provided on this slide.
Steven, slide 9: The Estonian Embassy is located in Washington D.C. The Estonian diplomatic mission to the United States is located in the Embassy Row neighborhood. Jonatan Vseviov currently serves as the Estonian Ambassador to the United States. Further information regarding the Estonian Mission to the United States is available by visiting the link provided on this slide.
Steven, slide 10: The United States Embassy is located in Tallinn, Estonia. Brian Roraff currently serves as the United States Ambassador to Estonia. The U.S. Embassy in Tallinn conducts diplomatic relations with the Republic of Estonia and coordinates activities of all U.S. government personnel serving in Estonia. Bilateral cooperation includes political, economic, commercial, defense and security, educational, and agricultural activities. Further information regarding the United States Mission to Estonia is available by visiting the link provided on this slide.
Steven, slide 11: In 2019, The Ohio State University undergraduates participating in a short-term, medical education abroad program had the opportunity to visit many educational and historic sites in Estonia. In this picture, Ohio State students along with Lorraine Wallace and Steven Mousetes are enjoying lunch at the University of Tartu. Information regarding the Ohio State University's "Exploring Medical Care Delivery and Education from a Global View: Finland and Estonia" education abroad program is available by visiting the link provided on the lower right corner of this slide.
Steven, slide 12: Section 2 provides an overview of Estonian population health demographics, including age structure, life expectancy, leading causes of death and disability, and an introduction to the United Nations Human Development Index.
Steven, slide 13: The figure compares and contrasts sex and age distribution of the Estonian population from 1992 and 2017. Over this 25-year period, changes in the Estonian population age structure are characteristic of an aging society. In 1992, both males and females under 24 years of age made up a significantly higher proportion of the Estonian population as compared to 2017. Similarly, in 2017, there were a greater number of Estonians aged 65 years and older as compared to 1992. [Data taken from a Latvian government report on health in the Baltics.]
Steven, slide 14: The figure depicts life expectancy in Estonia from 1960 to 2015, representing a 55-year time span. From 1960 to 1980, life expectancy remained steady at approximately 65 years of age. During the 1980s, life expectancy steadily climbed to just over 67 years of age by the end of the decade. In the years following the fall of the USSR, you will notice a steep drop in life expectancy in Estonia. Life expectancy plummeted during this time period in not only Estonia, but the majority of ex-Soviet states. Notably by 1993, life expectancy had dropped to approximately 60 years of age. Drop in life expectancy during this time period can be attributed to underlying factors such as economic and social turmoil. From the late 1990s to 2015, Estonian life expectancy continued to rise to just over 70 years of age. [Data taken from World Bank male life expectancy at birth data.]
Steven, slide 15: Data represented in this table are drawn from the 2018 World Bank report. In 2018, life expectancy in Estonia was lower than neighboring Finland at 79 years of age and the United States at 76 years of age. Notably, life expectancy in Estonia at 74 years of age was slightly higher than the other two Baltic countries of Lithuania and Latvia. [Data taken from World Bank life expectancy at birth data.]
Steven, slide 16: Data presented in this table are drawn from the University of Washington's Institute for Health Metrics and Evaluation. In 2017, similar to the United States, heart disease, stroke, and cancer were the leading causes of death in Estonia. [Data from Institute for Health Metrics and Evaluation mortality data for Estonia.]
Steven, slide 17: Data presented in this table are drawn from the University of Washington's Institute for Health Metrics and Evaluation. In 2017, the leading cause of disability included pain, falls, diabetes, depression, hearing loss, stroke, neonatal disorders, and excessive alcohol consumption. [Data from Institute for Health Metrics and Evaluation mortality data for Estonia.]
Steven, slide 18: The Human Development Index, referred to as HDI, is a summary measure for assessing long-term progress in three distinct markers of human development. The first marker is life expectancy. The second marker is education, which is measured by mean years of schooling received in a lifetime by those aged 25 years and older. The third marker is standard of living as measured by gross national income per capita. The figure on this slide is from the 2019 United Nations Development Program Report for Estonia. Over the past 30 years, 1990 to 2018, Estonia's HDI value has steadily increased from 0.730 to 0.882. Life expectancy, mean years of schooling, and gross national income per capita have increased in Estonia over this time period.
Steven, slide 19: Data presented in this table are drawn from the 2019 United Nations Development Program Report. Countries with a high human development index, referred to as HDI, above 0.80 are considered to be in the very high human development category. In 2019, Norway had the highest HDI of nearly 200 ranked countries throughout the world. The United States and United Kingdom tied for 15th with an HDI of 0.920. With an HDI of 0.882, Estonia is ranked 30th in the world and slightly above both Lithuania and Latvia.
Lorraine, slide 20: Section 3 provides an overview of how the Estonian health care system is structured, including the evolution from the Soviet era to the present day. Also discussed are the primary care foundation, healthcare workforce distribution, healthcare financing and expenditures, and determinants of health.
Lorraine, slide 21: The Town Hall Pharmacy, located in the heart of Tallinn's Old City, is one of the oldest continuously running pharmacies in Europe. The pharmacy, founded in approximately 1422, is also the oldest medical establishment in Tallinn. As shown in the photograph on the right, several centuries ago, patients could purchase such items as hedgehog or bat powder, and various potions and spirits. Today, Town Hall Pharmacy is a fully functional, modern facility, providing current, professional, medical advice and a wide variety of over-the-counter and prescription medicines.
Lorraine, slide 22: The University of Tartu was founded in 1632. There are approximately 13,000 students, including approximately 1,200 international students, representing 90 different countries. The university offers bachelor, master, and doctoral programs, including 26 programs in English. The University of Tartu houses the only medical school in Estonia.
Lorraine, slide 23: National health expenditures in gross domestic product, GDP, in 2016, 2017, or 2018 for 7 countries are displayed in the figure. Overall the proportion of GDP spent on health expenditures was similar in Estonia, Latvia, and Lithuania. Collectively, the 3 Baltic countries average between 6 and 7 percent GDP on health expenditures. Estonia currently spends approximately 1,600 Euros, approximately $1,900 U.S. dollars on health care per person. By comparison, health care spending across the European Union averages 2,900 Euros, approximately $3,400 U.S. dollars per person, while in the United States health care spending averages just over $11,000 dollars per person. While higher than Baltic countries', GDP spent on health expenditures in Canada, Japan, and the United Kingdom range between 10 and 12 percent. Notably at nearly 18 percent GDP, the United States leads the world in health expenditures.
Lorraine, slide 24: During the Soviet era, the Estonian health care system was highly centralized and geared toward hospital and multi-specialty care. Estonian policy makers faced significant obstacles in reforming their health care system in the midst of considerable instabilityfollowing the collapse of the Soviet Union. Over the course of the past 30 years, the Estonian health care system has undergone extensive, comprehensive legislative reviews of health financing, service provision, and regulation ofrelations between different parties. For example, purchaser, provider, and patient. The figure displayed provides an overview of the current Estonian healthcare system organizational structure. Healthcare financing is organized through the Estonian Health Insurance Fund. The health system is mainly publicly financed through payroll tax contributions. Approximately 96 percent of Estonians receive health care coverage through the Estonian Health Insurance Fund. [The figure on this slide depicts the different parts and agencies of the Estonian government, with the Estonian Health Insurance Fund falling under the Estonian Parliament, Government, and Ministry of Social Affairs. The Estonian Health Insurance fund then has oversight of family practices, hospitals, dental care, nursing care, pharmacies, public health services, ambulance services, and the Center for Health and Welfare Information Systems. More information can be found on the Estonian Health Insurance Fund’s website.]
Lorraine, slide 25: We recommend watching the five-minute e-Estonia video referenced at the bottom right of the slide. This engaging video provides an overview of the patient portal, digital prescriptions, e-ambulance and e-consultation services, interoperability, and international expectations.
Lorraine, slide 26: Estonia has a strong and comprehensive primary care system. As displayed in the table, over a 14-year time period, major shifts in the Estonian health care system occurred. In 1991, immediately following the collapse of the Soviet Union, national reforms focused on establishing primary care as the foundation of the health care system. Next in 1993, family medicine was recognized as a medical specialty. 10 years following Estonian independence, the Health Services Organization Act was passed, with primary care identified as the first point of contact for patients within the health care system. In 2003, a 3 year family medicine residency training program was established at the University of Tartu. The 24-hour family doctor hotline was established in 2005, which provided Estonians easy access to primary care. [More information is available through the Estonia: Health System Review PDF.]
Lorraine, slide 27: The great majority of Estonian physicians specialize in family medicine and serve as the first point of care. In 2016, Estonian adults on average made 6 annual physician visits, with nearly half of those to their family physician. Patients are able to identify a personal family physician through the Estonian registry. Additional information regarding this process is available by visiting the link at the bottom right of the slide. The vast majority of family physicians are contracted and paid through the Estonian Health Insurance Fund. With the exception of psychiatry, gynecology, dermatology, and ophthalmology, referral from a patient's family physician is needed for specialty consultation. Comprehensive specialty care is available in Tallinn, Tartu, and Parnu. These are the 3 cities with significant populations.
Lorraine, slide 28: In 2016, there were 32 physicians, 61 nurses, and 10 dentists in Estonia per 10,000 people. Recent estimates from Eurostat indicate that too few physicians and nurses are currently being trained in Estonia to meet future population health care needs. [More information is available through the Estonia: Health System Review PDF.]
Lorraine, slide 29: The determinants of health are global. With the current pandemic, you may have heard discussions from public health officials, from politicians, or in the media about the determinants of health. The U.S. Department of Health and Human Services asks, what makes some people healthy and others unhealthy, and how can we create a society in which everyone has a chance to live a long, healthy life? It is the interrelationships among these factors that determine individual and population health. Because of this, interventions that target multiple determinants of health are most likely to be effective. Determinants of health reach beyond the boundaries of traditional health care and public health sectors. Sectors such as education, housing, transportation, agriculture, and the environment can be important allies in improving population health. [More information from the CDC on Social Determinants of Health.]
Lorraine, slide 30: As mentioned, the determinants of health are global. The Commission on Social Determinants of Health was established by the World Health Organization in March 2005 to support countries and global health partners in addressing the social factors leading to ill health and health inequities. The Commission aimed to draw the attention of governments and society to the social determinants of health and in creating better social conditions for health, particularly among the most vulnerable populations. [More information on the WHO’s Commission on Social Determinants of Health.]
Lorraine, slide 31: Behavioral risk factors account for almost half of deaths in Estonia. An unhealthy diet is a major public health issue in Estonia. Nutrition in Estonia can be improved many different ways, including by reducing sugar, salt, and fat consumption, and increasing fruit and vegetable consumption. Tobacco use is still a major public health concern in Estonia, particularly among men even though smoking rates have steadily decreased since the year 2000. Currently more than one-fifth of the adult population smokes on a daily basis. In 2014, nearly 1 in 4 adults reported binge drinking at least once a month. Similar to many other risk factors, the difference between men and women is striking. 37 percent of men binge drink while only 9 percent of women do. 1 in 5 adults are obese, which places Estonia with the third highest obesity rate in the European Union. Estonians are less physically active than the European Union average with 60 percent of adults doing at least 150 minutes of moderate physical activity per week, compared with the European Union average of 64. [More information on the WHO’s Commission on Social Determinants of Health.]
Lorraine, slide 32: Section 4 describes personalized or precision medicine and provides an overview of the Estonian Biobank.
Lorraine, slide 33: Listed on this slide is a definition of personalized medicine from the National Institutes of Health. Personalized medicine focuses on using genetic or other biomarker information to make treatment decisions about patients. These could include decisions about who should get certain kinds of therapies, or specific doses of a given therapy, or who should be monitored more carefully because they're predisposed to a particular safety issue. Personalized medicine is generally comprised of two elements. One is the drug, biologic, or other therapeutic intervention and second is the diagnostic test.
Lorraine, slide 34: In Estonia, the Human Genes Research Act was established in December 2000. The act ensures that patients remain anonymous, enables donors to decide which studies they want to participate in, and gives donors full control over who has access to their data. By studying the genetic data of the Estonian population, scientists can improve their understanding of heredity diseases and the interaction of genetic and environmental factors. [WHO information and overview of The Human Genes Research Act.]
Lorraine, slide 35: The Estonian Biobank is housed at the University of Tartu. As set by the Human Genes Research Act, the Estonian Biobank promotes the development of genetic research, collects information on the health of the Estonian population, and genetic information concerning the Estonian population and uses the results of genetic research to improve public health.
Lorraine, slide 36: The cohort size is currently 200,000 gene donors, all of whom are 18 years of age or older. This closely reflects the age, sex, and geographical distribution of the Estonian population. The breakdown of the participant representation is 83 percent Estonian, 14 percent Russian, and 3 percent from other nationalities. All subjects were recruited randomly by family medicine practitioners or physicians in hospitals. Participants are individuals who opted to join the Estonian Biobank after learning about it through various sources, such as promotional events, media, and/or friends. [More information on the Estonian Genome Center.]
Lorraine, slide 37: During a one to two hour doctor's appointment, participants complete the computer assisted personal interview, which is a comprehensive questionnaire. This questionnaire is comprised of multiple sections, including personal and family history, educational and occupational history, and lifestyle factors. Medical history and current health status, including medication intake are also recorded. During the interview, a doctor will also document a patient's height, weight, waist circumference, blood pressure, and resting heart rate. Additionally, 30 to 50 milliliters of venous blood are taken and transported to the Estonian Genome Center to be analyzed and stored for future use. There is a team of approximately 50 people working at the Estonian Genome Center. The research unit is divided into three work groups, including biostatistics, bioinformatics, and functional genomics. [More information on the Estonian Genome Center.]
Lorraine, slide 38: Section 5 provides links to additional Estonian health related resources.
Lorraine, slide 39: Thank you for your interest in the Estonian health care system. We hope you found our presentation to be both informative and helpful, and we hope we've sparked your interest in learning more about the Slavic and Baltic countries. [Links for further information: e-Estonia, Estonia Health System Review, Estonian Chamber of Commerce and Industry, Visit Estonia, and What the U.S. Medical System Can Learn from Estonia June 25, 2019 article in The Atlantic.]