1. How institutions can work together to ensure financial sustainability
by Ivi Normet
Ministry of Social Affairs of Estonia

2. the role of the MoSA in health financing policy in Estonia

3. Estonia’s health system is largely publicly financed through an earmarked tax on wages (the social tax). 2/3 of total health financing comes from the social tax. The single payer system – autonomous agency Health Insurance Fund (EHIF).

4. The health insurance is separated from other forms of social insurance (e.g. pensions and unemployment benefits). EHIF is governed by a 15-member Supervisory Board, with the Minister of Social Affairs as its Chairman.

5. At national level, the MoSA is responsible for health, social and labour policy.
MoSA is responsible for overall health system stewardship regarding:
policy development,
regulation and supervision of health services.

6. The MoSA finances services available to the whole population such as emergency care, public health programmes, emergency care services provided to uninsured individuals etc.

7. Main policy document
National Health Strategy 2008–2020 follows the health for all principles and sets out the basis for all activities and investment areas for all ministries and agencies that aim to improve the public health situation in Estonia.

9. responding to the challenge of financial sustainability

10. Health system analysis
Health System Performance Assessment
Analysis of Financial sustainability of health financing (cooperation with WHO)
Analysis of Financial sustainability of social insurance system (cooperation MoF)

11. Broaden the public revenue base
non-employment-based taxes on capital and consumption;
social tax to dividends from capital investment;
central government contributions to EHIF
Improve financial protection
review user charge policies for all health services

12. Improve health system performance through better resource allocation and purchasing
MoSA should develop a stronger strategy for guiding investment in and the design of hospital infrastructure.
.....work closely with other ministries to generate sufficient investment in public health programmes and prevention
work with EHIF to boost the primary care focus of the health system.

13. Maintain strong governance of the health system
Monitoring and evaluating provider activity across the health system
Investing in e-health
Providing policy direction for the whole health system, ensuring a sufficient flow of resources...

14. respond to the financial crisis

15. Social tax and EHIF expenditures, 2001 – 2012
euros

16. Monitoring the impact of crisis

17. Decisions affecting health system made due to financial crisis
cancelled compensation of capital costs from the state budget to Health Insurance Fund (EHIF)
increased general value added tax (18%→20%)
increased the value added tax on medicines (5%→9%)
decreased funding of public health programmes (26%) - mainly NCD, but also ambulance services budget (3.4%)
increase of unemployment tax (0.9%→1.5% → 4.2%)

18. Priorities and measures to maintain health
EHIF started use its accumulated reserves
health budget is less affected than general state budget and other sectors
within health budget primary care and communicable diseases prioritised
rising of excise taxes for tobacco and alcohol (four times since 2008)
state contributes insurance of unemployed
state pays for emergency care of uninsured people

19. Other measures
use of EU structural funds: acute and nursing care hospitals infrastructure + public health activities
use of funds from carbon dioxide quota trading to renovate hospitals more energy saving
use of Norway and Swiss grants