The National Audit Office assessed how the situation in the healthcare sector has changed since the National Audit Office’s annual report for 2022, which was also devoted to trends in Estonian healthcare. The problems highlighted four years ago and in subsequent audits – the long-term uncertainty in healthcare funding, shortage of healthcare professionals, healthcare arrangements that no longer meet the changing needs, and the postponement of necessary decisions – remain unresolved. At the same time, progress has been made in children’s health check-ups, the use of e-consultations, the organisation of the work of family physicians and the modernisation of the healthcare quality system.
“In healthcare, there is no shortage of knowledge about what the problems are, nor of ideas on how to solve them,” said the Auditor General Janar Holm. “The question is which changes we will ultimately be able to implement and how they will improve care for patients. Announcing new reforms is of little use if there are no staff, no funding or no way of assessing whether things actually improve for people. The Ministry of Social Affairs must decide what to do first, what to do later, and what it cannot do at present.”
Healthcare expenditure in Estonia increased by approximately 61% between 2020 and 2025, reaching over €3.3 billion in 2025, of which approximately €2.5 billion was covered from public funds. The rise in costs has been driven by more frequent use of services, the increasing complexity of treatment, and the general price increase, which in the healthcare sector has been exacerbated by wage increases and the rising costs of medicines and technology.
Solutions for the long-term funding of healthcare have been repeatedly promised in government action programmes, but no decisions have been made. Temporary solutions have been found and cost-saving measures planned to cover the deficit in the coming years. However, these solutions do not provide an answer to the question of how much and from which sources healthcare should be funded in the long term, as the population ages and the need for treatment grows. These decisions must be made by the Government and the parliament.
Three interrelated issues must be addressed: how much public funding to raise and from which sources; what proportion of costs should people pay themselves and what proportion should be covered by other private funding sources; and how to achieve better treatment outcomes with the available funding. In Estonia, out-of-pocket payments accounted for 21% of total health expenditure in 2024, whilst the European Union average, based on the data for 2023, was 15%. For people with substantial healthcare needs or lower income, out-of-pocket payments may be a barrier to accessing the care they need.
Access to specialised medical care has not improved despite increased funding. In 2025, the Health Insurance Fund’s expenditure on specialised medical care was approximately 70% higher than in 2019, a year before the coronavirus pandemic, whilst at the same time the number of outpatient appointments decreased by 8%.
The waiting times for specialised medical care vary depending on the specialty, healthcare facility and region. The maximum waiting time for specialised outpatient care has been set at 42 days, but in March 2026 the median waiting time exceeded this in many specialities and at several healthcare facilities. Over 10,500 initial appointments with a waiting time of more than 60 days had been booked in the same month, and in more than a third of these cases, patients had to wait over 90 days for their appointment. For example, in some healthcare facilities, the median waiting time for an appointment with an ophthalmologist or an ophthalmic nurse was as long as 126–208 days, and for an appointment with an endocrinologist or a cardiologist, it was over 110 days. In reality the waiting time for an appointment may be longer than the measurable length of the waiting list, as in some cases it is not possible to book an appointment due to a lack of available slots.
A positive development is that the number of e-consultations has tripled compared with 2021. The healthcare professional treating a patient can use an e-consultation to digitally request the opinion of a professional in another specialty regarding the continuation of treatment or the referral of the patient for an appointment. In approximately a third of the cases, a digital treatment recommendation from a doctor or nurse is sufficient, and the patient does not need a separate appointment. This makes it possible to use the time of doctors better and means that some health concerns can be resolved more quickly. However, e-consultations alone do not resolve the shortage of appointment capacity in specialties where there is a shortage of staff.
The shortage of family physicians is affecting an increasing number of people. The number of people on practice lists without a permanent family physician has increased from approximately 72,500 in 2022 to nearly 110,700. The average age of family physicians is rising, and more than half of family physicians with a practice list are already 60 years old or older. Whilst the network of health centres has expanded and team-based work and remote services are being tested, maintaining the existing working arrangements uniformly everywhere is no longer realistic.
The Ministry of Social Affairs should develop a system for organising primary care that takes the long-term labour shortage into account and ensures that people know where to seek help and who is responsible for the continuity of their treatment.
If a person is unable to access primary care, specialised care, nursing care or the necessary social services at the right time, or is unable to reach a suitable care provider, their health concerns may compel them to go to the emergency department or call an ambulance. In 2025, there were over 452,000 visits to the emergency department, which is nearly 5% more than in 2021. The share of cases in the non-urgent or green triage category was 58%. This does not mean that the visits were unjustified, but some of these health concerns could be addressed outside the emergency department if suitable care were available. To this end, people need to know where to turn and, if necessary, receive help in accessing the appropriate service. Primary care, out-of-hours care, the emergency number (112) and the family physician’s helpline (1220) do not yet operate as a unified system in which the necessary information is shared and where people are directed to the appropriate care in accordance with uniform principles.
Similar problems arise at the points where nursing care and social services intersect. A person’s stay in inpatient nursing care may be extended even if they no longer require it, but the necessary general care service or home nursing care is not available. This reduces the availability of nursing care for those who actually need it.
The shortage of healthcare professionals cannot be resolved simply by training more doctors and nurses – it is just as important to retain existing professionals and make better use of their skills. The number of healthcare professionals and the number of study places have increased in comparison with 2022, but the labour shortage has not decreased significantly. The volume of overtime hours remains high and has increased compared to 2020. Over the next decade, a large number of healthcare professionals will need to be replaced due to their age. In 2025, 44% of doctors and 29% of nurses currently working in the healthcare sector were 55 years old or older. The proportion of doctors aged 65 or over amongst all doctors working in the healthcare sector rose from approximately 18% to 24% from 2015 to 2025. As the population ages, increasing the number of healthcare professionals and the training volumes continuously may no longer be feasible, as fewer young people enter the labour market, whilst demand for healthcare services continues to grow. Therefore, alongside training the next generation, it is therefore important to retain existing staff, encourage former professionals to return to the healthcare sector, and allocate tasks in such a way that specialists can focus on work that requires their specific skills.
The abundance of development plans and reforms has not yielded a similar abundance of solutions for the healthcare sector, as ambitions exceed the capacity to implement them. As of September 2026, there were 16 strategy documents in addition to the National Health Plan and its programmes, with a further seven currently being drafted or planned. Despite all these strategic documents, it is not always clear for stakeholders which agreements are binding on public authorities, who is responsible, and where the funds required for implementation will come from. For example, compiling the National Medicines Policy 2030 took three years, but after its completion in 2023 an official implementation plan has still not been approved.
“Judging by the abundance of development plans, we could look into the future of healthcare in Estonia without many concerns,” said the Auditor General Janar Holm. “Unfortunately, the increasing availability of development plans has not yet ensured more available medical care. The Ministry of Social Affairs must decide which changes can actually be implemented given the current staff, funding and IT capacity. What matters to the patient is when their appointment is, not the deadline for the completion of yet another development plan.”
For example, work is currently underway on the reform of the integration of health and social care services, the development of new principles for the funding of specialised medical care, and the implementation of care pathways to organise the movement of patients between different stages of treatment and healthcare facilities. These changes rely in part on the same staff, funding and IT solutions.
Healthcare reforms themselves also require triage – that is, a decision as to which changes are most urgent and which can be implemented with currently available resources. The Ministry of Social Affairs should look at major reforms and development projects as a whole and determine what should be done first and what later. Otherwise, the reforms may hinder one another, and their impact on patients’ access to care may be smaller than expected, or even non-existent.
Progress is being made in prevention but detected health concern must also lead to the necessary care. People in Estonia are living longer, but the number of healthy life years has not increased at the same rate. In 2025, life expectancy was 75.6 years for men and 83.6 years for women. Of these, an estimated 55.2 and 59.3 years, respectively, would be lived without health problems that limit people’s daily activities. The significant gap between the number of healthy life years in Estonia and the European Union average has not decreased. To improve the situation, it is important to prevent and detect diseases at an early stage and to ensure continuity of care.
There has been significant progress in children’s health check-ups. Whilst the earlier observation showed that approximately half of children aged three to six had completely missed their health check-ups over a three-year period, the proportion of such children from 2023 to 2025 was approximately 10%. However, only 15% of children attended check-ups in all three years, i.e. as frequently as recommended. Vaccination coverage among children remains below target levels. For example, 83.1% of two-year-olds had been vaccinated against measles, mumps and rubella in 2025, but the target is 95%, and there were significant differences between counties. Low vaccination coverage increases the risk of disease outbreaks.
Over 60% of the target group take part in breast, cervical and colorectal cancer screening, but the national target of 70% has not yet been achieved. There is no comprehensive overview of whether the people with suspected cancer or precancerous lesions detected during screening are given further tests, have their diagnosis confirmed and, where necessary, start treatment in a timely manner. This is hindered by problems relating to data sharing and data quality, which the National Audit Office already highlighted in its 2021 audit. The treatment and monitoring of chronically ill patients is not sufficiently consistent either.
“For the patient, what matters is whether their condition is detected in time, whether they receive the necessary treatment, and whether it is effective,” said Janar Holm. “Counting the appointments and tests alone is not enough to assess this. We must also be able to notice the people whose treatment has not been completed or whose health is not improving despite treatment and ensure that they receive the help they need.”
Background
In its annual report, the National Audit Office assessed the changes that have taken place in the Estonian healthcare system since the 2022 annual report. The report is based on audits and additional analyses carried out since the previous report, and covers prevention, access to and quality of treatment, the healthcare workforce and the governance of the sector.
