Estonia Could Be the Country with the Healthiest People and Economy in the World

22 January 2024

It's rarely considered that better health of the population can be a new and very important source of economic growth. Discussions often focus mainly on healthcare costs, however several studies suggest that better health could be more important for economic growth in the coming decades. We have all the prerequisites to become the world's healthiest nation - a clean environment with plenty of space for movement, healthy local food, and a digital government infrastructure that is already among the best in the world.

According to McKinsey, Estonia's GDP could increase by a tenth if premature mortality decreased and people stayed in the labor market longer. Good health also increases work capacity and productivity - one euro invested in health yields 2.4 euros in return.

The impact of the healthcare system on public health is surprisingly small. points out that the medical system accounts for 11 percent of the final health outcome, while health behavior and lifestyle account for as much as 36 percent. Our future is bright if health behaviors improves across the entire population, which would mean that people need to become active participants in their own health decisions and outcomes. Unfortunately, this does not happen by itself; it requires vision at national level, creating both motivation and opportunities.

Today's Healthcare System Soon Needs a Life Support Equipment

Chronic underfunding of Estonia's healthcare system is no news to anyone, as long-term trends are materializing - an aging population, increasing burden of lifestyle diseases, decreasing tax revenues and more importantly, a decreasing number of doctors, with 1 out of 2 general practitioners and mental health specialists being of retirement age. In other words, costs are growing faster than revenues. Additionally, we are witnessing long waiting lists for specialist care, and problems at other levels of care are piling up in nursing care and emergency medicine.  People cannot access doctors and treatment often starts later than it should, causing greater harm to health and putting further strain on a healthcare system already suffering from staff shortages and increasing healthcare costs.

There is also a growing staff shortage in the field of mental health. Over half of psychiatrists are of retirement age or will reach retirement age soon. According to the National Institute for Health Development, Estonia has about 15 psychiatrists per 100,000 people, which is significantly less than in the Nordic countries. For comparison, the number of psychiatrists per 100,000 people is 26 in Norway, 24 in Finland, 23 in Sweden, 23 in Lithuania, and 16 in Latvia.

Healthcare costs per capita have risen sharply since 2003 when it was 327 euros per person. In 2022, the costs were nearly two thousand euros per person.

Maintaining Current Service Levels means that Health Insurance Fund Costs Will Grow 24% Faster Than Revenues by 2035.

The Centre for Development Monitoring said in its analysis in 2020 that if no fundamental changes are made to the system, by 2035 people's premiums and co-payments could double, waiting times for treatment could lengthen further, and the health insurance budget could reach a deficit of €900 million.

Low health awareness and lack of responsibility for one's own health lead us to an early grave.

We also give minimal attention, far below what is necessary, to the broader field of healthcare, for example, raising health awareness and secondly, prevention, not only in terms of activities directly related to disease, such as screening and genetic testing, but also in terms of health awareness and education, and a healthy environment.

We are accustomed to relying on the medical system, doctors, and medicines to cure us in case of trouble. Few are used to thinking that our health depends primarily on ourselves; my mental and physical well-being is primarily my own responsibility, and only then can I seek help and demand treatment from the medical system if necessary. As time goes on, personal responsibility becomes more critical, as today's availability of medical care is a luxury that will become increasingly scarce without fundamental changes.

According to recent studies, 50% of all deaths are directly related to health behavior such as diseases resulting from unhealthy lifestyles (alcohol, tobacco, high sugar, lack of exercise) and obesity-related cardiovascular diseases, chronic lung diseases, some types of cancer or diabetes. These are diseases whose causes are largely rooted in our lazy and over-consuming modern lifestyle, including high alcohol consumption, where Estonia still ranks in the top ten in the world.

In financial terms, we lose 1.5 billion euros every year in Estonia to lifestyle diseases and premature deaths. In addition to direct treatment costs, lifestyle diseases cause significant non-health-related costs, such as reduced productivity and informal care costs due to mortality and morbidity. For example, in 2015, the reduction in productivity due to lifestyle diseases was estimated at 54 billion euros in the European Union. At the same time, control and prevention of these diseases are highly productive - the American health organization has calculated that every dollar invested in preventing lifestyle diseases will bring back nearly seven dollars by 2030. It's hard to find newer calculations for Estonia, but since the prevalence of lifestyle diseases is on the same scale worldwide, the idea remains the same.

Relating to alcohol, consumption per adult increased by 2.1% in 2021, and consumption has been increasing since 2019. In 2022, an Estonian drank an average of 11.2 litres of pure alcohol, equivalent to 678 bottles of beer a year. Nearly 90 percent of survey respondents said they could reach the nearest alcohol sales point in less than 10 minutes. Since 2020, the number of sales points has been continuously increasing, and alcohol is also available through e-commerce and fast couriers. Henrik Kalmet wrote a good breakdown of Estonia's alcohol problem in December.

If universal health insurance were to cost about 79 million euros a year at current spending levels, then reducing the years of lost life due to alcohol by 20% would increase people's well-being and state revenues by ten times a year. Compared to the current situation, a one percent reduction in alcohol consumption resulting in lost years of life would mean an annual gain of 28 million euros. In connection with smoking it would be 30 million and for mental health disorders 29 million euros a year.

It seems we desperately want to belong to the Nordic countries in all indicators, but as soon as we talk about changing alcohol policy, we decide to mentally position ourselves to "post-Soviet" world.

1.5 Billion Euros Hidden in Raising Health Awareness

Just as financial literacy is increasingly being taught in schools, health education should also be integrated into primary school curricula, helping to understand the foundations of a healthy lifestyle and how to do as much as possible to maintain mental and physical health. The state must actively guide healthy living not only through a healthy environment but also by "nudging" residents towards better health behavior. The basic program would require relatively little, i.e., focusing on the 20% of lifestyle choices that affect 80% of health also known as the holy trinity: nutrition, movement and sleep.

Greater health awareness, more effective preventive activities, earlier diagnosis and  reduced need for treatment translate quite directly into euros. Preventable mortality per 100,000 people in Estonia is 50 deaths higher than the EU indicator. If Estonia's indicator improved to the EU level, as a result, we would gain about 24,000 additional life years due to improved treatment quality, achieving direct welfare growth and a financial gain of 1.5 billion euros.

Technology is not a Panacea, but Without it, the Patient Does Not Heal

Estonia has a national artificial intelligence action plan, which unfortunately lacks a greater focus on health. Among other things, the UK government has set up a separate artificial intelligence working group in its Innovation and Science Office and their artificial intelligence strategy says that the UK's goal is to be a world leader in artificial intelligence-related knowledge, security, and implementation. The UK government has also invested 250 million pounds to accelerate the adoption of artificial intelligence in healthcare.

How much has Estonia invested?

Another example from the UK: before adopting any new technology, an assessment is performed to calculate the financial cost per additional life year added by that particular technology. A threshold has been set which all new technology must exceed in order for the state to support its adoption. The methodology used in the UK is simple to adopt and apply in Estonia.

Thus, the adoption of new health technologies, the use of health data, and the digitalization of the medical sector should be vigorously led and supported by the state, enabling rapid assessment of the impact of new technologies, piloting, and, if benefits are apparent, preferential adoption across Estonia. Especially considering that successful pilot projects could lead to solutions scalable to other countries, which would have a much greater chance of breaking through globally with the presence of the Estonian e-government quality seal. If these companies keep their headquarters in Estonia, tax revenues also come here. Success stories would also raise Estonia's dormant e-state image to a new level.

A significant resource is hidden in the medical sector's low level of digitalization and lagging behind other sectors. At primary care level, about 40% of a doctor's and nurse's time is spent on administrative tasks and documentation, leaving very little time for patient care. Patients are still given a paper pack with medication or diagnosis information; procedure times are marked in a yellow in a vaccination passport-like folder. Everything related to administrative tasks, documentation and data analysis should be automated and digitalized as quickly as possible, thereby freeing up more resources for clinical work. We are only just considering providing family doctor services remotely, although such solutions have long been in use in the private sector and have proven effective, as only 15% of patients need critical care. We are wasting resources and nerves, both of doctors and patients.

I have brought forth proposals that could have the most fundamental impact on public health and, therefore, the economy. Excluded from the list were changes related to the healthcare financing model, reducing the availability of strong alcohol, vigorously strengthening primary healthcare by investing in the training of doctors and nurses (including training abroad and bringing in foreign labor), and the increasingly significant role of employers in supporting their employees' mental health and improving health behavior. We must understand that today's medical system and the desire to have instant access to a doctor for all health concerns is a luxury that will soon run out. However, it seems that we lack both vision and a Plan B.

In conclusion, one more interesting and worrying connection: if we continue in the same way, people's health behavior and access to treatment will become even more unequal, which in turn deepens dissatisfaction and distrust towards the state. Distrust towards the state is a direct security risk, meaning the issue suddenly becomes even more critical than poor public health trends and the Health Insurance Fund's budget deficit.