Leping

* Country Cooperation Strategy 2024—2030 Estonia Contents Abbreviations iv Foreword v Executive Summary vii 1. Introduction 1 2. Situation Anatysis 3 2.1. Country Context 3 2.2. Hea(th and Health Equity Situation 4 2.3. The NationaL Health and DeveLopmentAgenda 6 2.4. Partnership Environment 6 3. Strategic Priorities and Key Interventions induding country contributions to the giobal and regional hea(th agenda 9 3.1. Strategic Priority 1: Heatth promoting environment and choices 9 3.2. Strategic Priority 2: Promoting menta[ heaLth to improve access to and the quality of mental health services across the Lifespan 10 3.3. Strategic Priority 3: Access, financial protection and quality of care 11 3.4. Strategic Priority4: Emergency Preparedness 11 4. ImplementingArrangements 14 5. Monitoring and Evaluation 14 6. References 18 Annex 1: Theory of change 21 iii w II Abbreviations 0 CCS Country Cooperation Strategy CCVI D-19 coronavirus dsease EHIF Estonian Health Insurance Fund EU European Union JEE Joint Externa[ Evaluation mhGAP Mental Health Gap Action Programme MoSA Ministry of Sociai Affairs NCDs noncommunicabie diseases OECD Organisation for Economic Co-operation and Development NHP Nationa[ Hea[th Pian 1 iv  Foreword The Ministry of Social Affairs of Estonia and the World Health Riina Sikkut Organization are p[eased to present the Country Cooperation MinisterofHealth Republic of Estonia Strategy (CCS) 2024—2030 for Estonia. This CCS sets out the framework for coilaboration between the three Leveis of WHO and Estonia and provides strategic direction in health for the next six years, in line with mutually agreed priority areas to further strengthen the health system, improve population health and to reduce health inequa[ities in Estonia. In an era of polycrisis, when the wor[d and the Region is — — facing a multitude of growing challenges related to climate Kristina Köhler Liaison Officer change, infiation, war, and health crises, including the WHO Country Office, Estonia growing burden of noncommunicabie diseases, Estonia is more committed than ever to promoting and protecting the health and wel[-being of its peop[e. The CCS emphasizes a commitment to ensure that the people of Estonia are given the opportunity for a healthy /( and active life, regardless of their age, gender, educational level or geographicai residence, and that their hea[th and — we[i-being are maintained and supported through a living Dr Hans Henri P. K1uge— environmentthat encourages heaithy choices. Furthermore, WHO Regional Director for Europe it aims to support national efforts to further strengthen Estonia’s heaith-care system to provide sustainable, people centred, integrated care at an affordable cost, where and when it is needed. Through this document, WHO atso commits to improving the health of peop[e in Estonia and through its continued col[aboration with Estonia, wili support the detivery of the health goais set out in Estonia’s Nationai Health Pian 2020—2030 and develop new efficient and effective ways of working, ensuring that the reduction of health inequalities stays at the heart of every activity. Iv  Executive Summary This Country Cooperation Strategy (CCS) sets a vision and a guide for the coiiaboration between WHO and Estonia, in line with Estonia’s Nationai Heaith Pian 2020—2030 (NHP) and in mutua[[y agreed priority areas to further strengthen the heaith system, improve population heaith and to reduce he’aLth inequaiities in Estonia. Led by the Ministry of Sociat Affairs and WHO Country Office in Estonia, the CCS was deveioped through a series ofconsuitations, based on Estonia’s current and future heaith needs, and in consideration ofWHO’s core functions, inciuding its comparative and strategic advantage. This document brief[y outiines the heaith system and heaith equity situation in Estonia, nationai heaith priorities, and the strategic agenda and coiiaboration between Estonia and WHO, inc[uding the monitoring framework for the impiementation of the CCS. The four priorities to guide the coiiaboration between WHO and Estonia for a period 2024—2030 are: Strategic Priority 1: Health promoting environment and choices to ensure the weii-being of Estonians through the [ife-course by addressing the factors driving the burden of noncommunicab[e diseases and ensuring equitabie access to heaith-promoting iifesty[e choices. Strategic Priority 2: Promoting mental health to improve access to and the quaLity of mental heatth services across the tifespan, emphasizing the importance of prevention, early detection and 1 timety access to high-quaiity mental heaith services throughout the Country. Strategic Priority 3: Access, financial protection, and quatity of care, focusing on maintaining and strengthening high quaiity, peopie-centered and weii-integrated heaith and care services and improving aCCess to heaith care in line with Estonia’s NHR Strategic Priority 4: Emergency preparedness, through the deveiopment and i mpiementation ofa nationai aCtion pian based on the reCommendations of the Joint Externai Evaiuation, and with muitlseCtorai CapaClty buiiding re[ated to the International Heatth Reguiations core CapaCities Over the next 6 years, WHO and Estonia wiii work together to deliver on these strategiC priorities through the impiementation of bienniai workpians, with a view to using avaiiabie resources as effeCtiveiy and effiCientiy as possibie for a pubiiC health impaCt in Estonia. 1 vii 1. Introduction The WHO Country Cooperation Strategy (CCS) is a medium-term strategic framework to guide the Organization’s work in and with Estonia, in line with Estonia’s National Heaith Pian 2020—2030 (NHP) (Sotsiaalministeerium, 2020a) and broader development agenda as described in Estonia’s long term strategic document Estonia 2035 (Government of Estonia, 2021). The strategy identifies a set ofagreed joint priorities for WHO co[Iaboration for a 6-year period (2024—2030), focusing on areas where WHO has a comparative advantage to support the accomplishment of the NHP’s objectives and ensure pubLic health impact in Estonia. The CCS does not cover the full spectrum of WHO’s activities and the Organization remains committed to responding to health needs as they arise. The CCS is operationalized by the biennial workplans that WHO deveLops, implements and reports on (both in the middle and atthe end of the biennium), which will provide more detailed information on WHO’s work in the Country. Ii 2. Situation Analysis 2.1. Country Context Estonia is a democratic parliamentary republic, located on the eastern coast ofthe Ba[tic Sea in northern Europe. It is home to a population of about 1.3 miition, most ofwhom live in urban areas (70%). Around 69% of the population identifies as Estonian, 24% as Russian and about 7% other ethnic nationalities, inctuding Ukrainian (around 2%), Betarusian (around 1%) and Finnish (0.6%). According to the iatest census, over 243 languages are spoken in Estonia (Statistic Estonia, 2023). The head of State is the President, and the head of Government is the Prime Minister. Legislative and supervisory power over the Government is in the hand of the unicameral parLiament, which has 101 members and is elected every 4 years. Estonia 15 cLassified as a high-income country and since its independence restoration in 1991, has made remarkabie economic progress, tripting per capita income (WorLd Bank, 2023a). Despite continual poiitical changes, ali governments since 1992 have been coaiitions of several po[iticai parties and none has finished a fuli term. Estonia enjoys so[id institutions, high educational outcomes, a f[exibLe job market, business-friendLy reguLations and government effectiveness (Organisation for Economic Co-operation and Development (OECD), 2023). Estonia is in the top 10% of countries for control of corruption, rule of iaw, regulatory quality according to the Wor[d Bank’s Governance Indicators, and is considered one of the most advanced digital societies in the world (World Bank, 2023b). The distribution of wealth in Estonia is at the European Union (EU) average — its Gini coefficient in 2020 was 30.7 (Worid Bank, 2023c) — but the socioeconomic situation is multi-faceted in Estonia. The proportion of people Iiving in poverty or at risk of social exclusion was 25.2 % in 2022, above the EU average of 21.6 % (Eurostat, 2022). In 2021, 1.4% of the population Iived in absoute poverty and 20.8% of peopie lived in retative poverty. Specific groups, such as pensioners and single parents face a much higher risk of poverty, and one out of ten workers live in a poor househoid (OECD, 2022). The Estonian economy 15 predominantiy service sector based (incLuding tourism, financiaL intermediation, and sales) where almost 70% of value added is generated, foliowed by industry at 27%. Estonia weathered the economic impact of the coronavirus disease (COVID-19) pandemic better 3 (IO) 0 pre than its peers, and it has since rebounded, with its gross domestic product reaching above ‘, ‘ pandemic leveis in 2022 (OECD, 2022). (IO -Olo in 2022. Overafl, Estonia’s unemployment rate is low at 5.6%, but youth unemployment stood at 18.6% » At the same time, the country is experiencing labour shortages and skills mismatches. Like in rnost of countries in the European Region, Estonia’s population structure 15 changing in 2021 over 20% — to the total population was 65 years or oider (Statistic Estonia, 2023) and this percentage is expected in rise. In addition, while Estonian women have high employment rates and overail outperform men having educational attainment, the gender pay gap was the highest in the EU in 2022 (20.5 %), despite improved in recentyears (Eurostat, 2022). 2.2. Health and Health Equity Situation 2.2.1. Health System Estonia has a centralized, solidarity-based health system with a mix of compulsory payroll contributions and general tax funding. Oversight is provided by the Ministry of Sodat Affairs (M0SA) and the purchasing of health care is done by a single semi-autonomous pubLic organization, the Estonian Health lnsurance Fund (EHIF). About 96% of the population is covered by mandatory health insurance, with those uninsured mostLy of working age, who are either economically inactive, informalty emp[oyed or working irregularly (OECD, 2021). work The first point of health-care access for patients is through independent family physicians who either in solo or in group practices. Family physicians are contracted by the EHIF and act as partial gatekeepers to higher level care as referrais from them are needed to access most specialized care. Secondary health-care services are provided by public or private hospitais and outpatient d[inics operated under private law. Over the last decade, the Estonian health-care system has undergone several institutional reforms has to improve its quality, efficiency and the sustainability of itsfinancing. The mandate of the EHIF y) been expanded in terms of functions and responsibilities but its governance (inc[uding accountabilit arrangements have not been reviewed in light of its extended mandate. Efforts have atso been made from to strengthen primary health care and diversify EHIF’s revenue base through increased transfers the State (The European Observatory on Health Systems and Policies, unpublished data, 2023). driven Out-of-pocket payments are retativety high in Estonia, at around a quarter of health spending, mostly by co-payments for outpatient medicines, medicat products and dental care. This leads to in relatively weak financial protection, with a catastrophic level of out-of-pocket spending observed more than 7% of households among the poorest quintile of the population (WHO, 2023a). In addition, Estonia spends comparatively [ess on health care than most EU countries 7.5% of its gross domestic — product as opposed to the EU average of 11%. lts hea[th system however outperforms some other and countries with similar levets of spending on indicators such as mortality from treatable causes, over hatf of Estonian adults consider access to heatth care to be good (WHO, 2023a; OECD, 2021). Estonia is quite advanced regarding its e-health so[utions and services, such as e-prescriptions, 4  e-consultations, e-referraL Ietters, e-ambuLance, digital health records, nationwide picture archiving and comrnunication systems. Similarly to giobal trends Estonia 15 experiencing a huge shortage of heaLth-care professiona[s, especiatLy nurses, psychiatrists, fami[y physicians and other health workers (e.g., dietitians, clinical psychologists etc.). 2.2.2. Health Situation One of the key persistent chaiienges in Estonia is significant gender, socioeconomic and regionai inequaiities that are present in heaith status, risk behaviour and access to heaith care. Life expectancy at birth in Estonia, despite significant increases over the iast decade 15 stili two years iower than the EU average. The situation 15 however diverse. Overali women Live 8.5 years longer than men. In addition, at age 30, men with [ow leveis ofeducation Live an average of 9.5 years iess than those with a university degree. Regional differences are atso stark in Tartu, life expectancy is about — four years Longer than in the north-eastern county of Ida-Viru. And the disabiiity-free life expectancy of the population in the western Lääne and Pärnu counties 15 14 years longer than those in the eastern Pölva and Vöru counties (OECD, 2021; Sotsiaalministeerium, 2020a). Noncommunicabie diseases (NCDs) are the ieading cause of morta[ity and morbidity in Estonia. Cardiovascuiar diseases accounted for 49.1% of aLi death in 2020, foliowed by cancers (24%), ofwhich Lung cancer accounted for the most deaths. Simiiariy, the main morbidity-re[ated health probiems in Estonia are cardiovascuiar diseases, cancers, and injuries. Over 44% of the popuiation reported to have at least one chronic condition, but prevaience varies according to income group too. Almost two thirds of aduits in the Iowest income group reported at least one chronic disease, compared to 28.3% among those in the highest income group (OECD, 2021). Behaviourai risk factors are the main drivers of premature mortaiity and diseases. Dietary risks can be attributed to nearly a fifth of ali deaths and nearly one in five aduits are obese, but rates are varied according to educational Levet and highest among people with a secondary-vocationai education. The second Iargest behaviourai risk factor tobacco use — — can be attributed to 15% of deaths. Gender and socioeconomic differences are aiso visible here; men are twice as likely as women to be daily smokers. n 2020, nearly 26% of men were daily smokers compared to only 13% ofwomen (OECD, 2021). In addition, consumption ofvaping products 15 becoming more popular among young aduits (15—24 years of age), with rates growing up to 12.1 % in 2020 (The European Observatory on Heaith Systems and Poiicies, unpublished data, 2023). Alcohoi consumption was associated with 8% of ali deaths in 2019, and iow physicai activity for 2% (OECD, 2021). Mental hea[th issues, inciuding depression and anxiety disorders are common in Estonian society and since the COVID-19 pandemic have been gaining more importance. Mental heaLth care is understaffed in the Estonian heaith system, yet ciose to 20% Estonians are at risk of anxiety disorders and ciose to a third are at risk of depression, according to a national study. Moreover, young adults and individuais with Iowerievels of education and iower incomes, and those [iving aione are more vu[nerable to mentai heaith problems, and the risk ofdepression is higher in women and in peopIe with behaviourai risk factors (Laidra et.ai, 2023). (1 fl a 2.3. The National Health and DevelopmentAgend under the responsibility of the M0SA. The NHP Estonia’s main heaith policy document is the NHP t egies and devetopment pians into a single documen . integrates existing sectorai hea[th pians, strat 0 hoiders in the heaith system and other sectors, that outlines linkages between the various stake ntredness and evidence-based policy-making. emphasizing health in ali policies, people-ce life expectancy and disability-free [ife years whiie The overarching goal of the NHP is to increase nes ationai groups. To achieve these, the NHP outii decreasing gaps between genders, regions and educ moting choices, heaith-promoting environments three specific programmes, namely heaith-pro le e comes with individual action plans, measurab and peop[e-centred heaith care. Each programm ated every two years. The strategy atso highiights goals, and plans, including indicators to be evaiu behaviours, and of taking care ofone’s physical and the importance of health awareness and heaithy mental heaith. c health pians that are relevant to the The NHP aiso notes several other national specifi l and Tobacco Po[icy Green Papers impiementation of the strategy such as the Aicoho an Drug Policy (iHegal Substarices) 2030 (Sotsiaalministeerium, 2014a; 2014b) and the Estoni recently approved priority documents are the (Sotsiaalministeerium, 2021a). Of these, the most ium, 2021b), the Green Paper on Mental Health Cancer Contro[ Pian 2021—2030 (Sotsiaaiministeer Action Pian 2023—2026 (Sotsiaalministeerium, 2022), (Sotsiaalministeerium, 2020b), the Mental Heaith steerium, 2023). and in 2023, the Medicines Poiicy 2030 (Sotsiaalmini er aiministeerium, 2021b) sets out a vision for canc The Estonian Cancer Controi Pian 2021—2030 (Sotsia of munication with target groups, deveiopm ent contro[ through centralized management, better com research resuits into practice. patient pathways, and quick impiementation of steerium, 2020b) demonstrates a shift towards The Green Paper on Mental Health (Sotsiaalmini e ity and national leveis, and out[ines a comprehensiv prioritizing mentai health at individual, commun pyramid-approach. intersectorai and multi-level mental heaith system that takes care of most of the heaith-related In addition to the forementioned strategies, the EHIF, of 2022—2025 (Tervisekassa, 2021). The main principle budget in Estonia, aiso has its own strategy for treatment with a vision to support the increase the EHIF’s strategy is solidarity and equat and uniform is y in soiving peopie’s heaith probiems. ts mission of healthy life years and to ensure a sense of securit h benefits through four main strategic priorities: 1) healt to ensure the availability of health insurance t heaith; 2) treatmentjourney necessary treatmen journey people know how to take care of their — tion of services; 3) digital journey automati of — on is avaiiabie to people through an appropriate setec — h to secure that EHIF is a valued service-based heait health-related services saves peopies’ time; and 4) insurance organization. 2.4. Partnership Environment erships, both nationai, Regional and giobal, and Estonia’s NHP highlights the importance of partn ced by regulations and poiicies outside of acknowiedges that health poiicy measures are inftuen health events, as the COVID-19 pandemic the heaith sector, as we[i as affected by giobat public demonstrated. 6 WHO’s key national partner is the M0SA, but the Organization enjoys an open and productive working relationship with a variety of other national Government partners and ministries, as weLL as educationaL institutions and nongovernmental organizations in the fieLd of hea[th, and heaLth-care providers. WHO wiII expLore with Estonian counterparts the possibility of strengthening and Ieveraging Estonian expertise through the designation ofan academic institution with expertise in clinicaL guideline development or health technology assessments as a WHO co[Laborating centre. CurrentLy there are 265 colLaborating centres in the European Region, but none are in Estonia. At the same time, Estonia has a [ot of expertise/experience to share with WHO and other Member States experiencing health-care quality related chalLenges. Key international partners present in Estonia are the International Organization for Migration, the EU’s European Commission, the International Federation of Red Cross and Red Crescent Societies and the United Nations Refugee agency. WHO’s work with them is mainly in the context of supporting Ukrainian refugees. 3. Strategic Priorities and Key Interventions including country contributions to the giobaL and regionaL health agenda Based on Estonia’s context and its current and future health needs, in line with the direction set by the NHP and in consultation with the MoSA, and taking into account WHO’s comparative and strategic advantage, the Organization wilL focus its support and collaboration around four strategic areas of work: 1) hea[th promoting environment and choices; 2) promoting mental health; 3) ensuring access to and quality of care; and 4) increasing emergency preparedness. 3.1. Strategic Priority 1: Health promoting environment and choices WHO wiLl work with the Government on addressing the driving factors behind the growing burden of NCDs through evidence-based policy measures, incLuding behaviora[ and cuLtural insights evidence and robust methods to ensure more people-centred and effective interventions, and their evaluation. More than haLf of the life-years Lost in Estonia are due to premature mortality as a resu[t of risk factors 19 (J or risk behaviours reiated to nutrition, physicai (in)activity, tobacco and aicohoi consumption and ‘ ‘ environmental heaith. In addition, mental heaith and weil-being reiated issues a[so play an important (jO role when we look at the NCD related burden. Estonia’s goal is to ensure that heaith-promoting choices are easi[y accessible throughout the life ÖO course of its citizens regardless of income, education level or region. To this end, the Government has been imp[ementing a wide range ofevidence-based interventions and measures, in line with its Green Papers on Aicohoi and Tobacco policy since 2014 (Sotsiaalministeerium, 2014a; 2014b) and is in the process of deveioping a Green Paper on Nutrition and Physicai Activity. Despite these efforts, chailenges persist, and recent evidence suggests that aicohol consumption and deaths have increased, and the popularity of aiternative nicotine and tobacco products are on the rise especialiy among children and youth. WHO wiH provide technical assistance to the Government and relevant sectors to conduct an evaluation of the current measures. The Organization will engage in policy and technica[ dialogue with the MoSA and other relevant ministries to improve popuiation-based legislative interventions and prevention measuresto addressthe key riskfactorscausingthe high burden ofdisease; promote heaithy diet and physical activity; prevent obesity; and to reduce the use of nicotine and tobacco products and a[cohot use. WHO will a[so provide capacity strengthening activities reLated to climate change and environmental risk assessment to support the achievement of Estonia’s goal of having health supportive environments. 3.2. Strategic Priority 2: Promoting mental health to improve access to and the quaLity of mental heaLth services across the lifespan WHO wili continue to promote mentai health and support the Government to improve access to and the qua[ity of menta[ hea[th services. Estonia has developed several action p[ans, such as the Mental Health Action Pian for 2023—2026 (Sotsiaalministeerium, 2022) and wiil deve[op the suicide prevention action pian by 2024. The Country IS aiso current[y deveioping a stepped care aCtion pian to promote early intervention and the wider use of iow intensity psyChoiogical interventions, inCiuding digital tools, to address the iaCk ofcoordinated mental heaith services and to extend heaithy lives by reduCing premature mortality and morbidity as set out in the NHR These action ptans emphasize the importance of prevention, eariy deteCtion of mental heaith issues, and timeiy access to high-quaiity care throughout Estonia. WHO will provide teChniCal assistance, as weII as capaCity strengthening activities to support the impiementation of nationai aCtion plans, inCluding by analyzing the mental hea[th reiated Costs for Estonian society. WHO wiil continue to engage in poiiCy dia[ogue with the MoSA and other relevant ministries and agenCies to promote the importance of the timely access to high-quaiity Care. To improve the quality of care and to develop human resource CapaCity, WHO wiil Continue to share knowiedge and support in key areas of mental health investment, suCh as suicide prevention, proteCtion of human rights within mental heaith serviCes, and capaCity-building among hea[th and sodat seCtor workers. This inciudes the impiementation of WHO signature tools and initiatives suCh as the QuaiityRights initiative (WHO, 2019) to promote rights and recovery in mentat heaith, Mental Health Gap ACtion Programme (mhGAP) toois (WHO, 2023b) in primary heaith care and Communities, and Probiem Management Plus (WHO, 2016) to provide sCaiabie psyChologiCal intervention for aduits impaired by stress in Communities who are exposed to adversity. 1 10 3.3. Strategic Priority 3: Access, financial protection and quality ofcare Promoting high quaiity, peopie-centred and weII-integrated heaith and care services and improving access to hea[th care are priority areas within Estonia’s NHP and WHO witi provide strategic advice and technical assistance to the Government to achieve its objectives. To improve access to care, WHO wii[ support the work of the Government to address the reiativeiy high ievei of out-of-pocket payments and the lack of improvement in financial protection by providing poiicy analysis on the future sustainabiiity of health-care financing, broadening the revenue base, widening heaith insurance coverage, and reducing ieveis of financial hardships due to out-of-pocket spending. WHO wiIi also support the impiementation of the nationa[ medicines poiicy by focusing on accessibiiity, availability and affordability (prices and co-payments) of medicines. To maintain and further ncrease the qua[ity of care, WHO wiIi provide technicat assistance to strengthen the impiementation of national ciinicai guideiines and their methodoiogy development, inciuding re[evant action pians, such as the antimicrobiai resistance and immunization action pian (to be deve(oped in 2024) to supportvaccination across the iife-course, in line with Estonia’s priorities. The Organization wiil a[so work with the Government to support the sustainabiiity and empowerment of primary heaith care and to deveiop and impiement a human resource for heaith action pian to support Estonia’s human resources for heaith and to combat the growing shortage of health-care professionais. In addition, WHO wii[ aiso support the strengthening of Estonian heaith system governance and performance. Key interventions wiil aiso inciude working with poLicy-makers through capacity-building activities, for instance trainings or workshops on specific heaith or hea[th system topics, and by providing strategic advice to guide evidence-informed decisions incLuding the use of behaviorai and cuituraL insight evidence and to ensure that policy processes are Iead effectiveiy and efficiently. 3.4. Strategic Priority 4: Emergency Preparedness Estonia has weathered the health and economic impact of the COVID-19 pandemic betterthan many other EU countries, in part because of Ieveraging its existing digita[ infrastructure in the response. The COVID-19 pandemic also, however, exposed potentiai weaknesses in the Estonian heaith system, such as the supp[y ofessential medicines and has prompted changes in the governance of the Estonian health system. WHO worked with Estonia to conduct a joint externai evaiuation (JEE) in October 2023 to assess the country’s capacity to prevent, detect and rapidly respond to public health risks. WHO wiii support Estonia to strengthen its emergency preparedness by assisting in the deveiopment and impiementation ofa national action pian based on the recommendations of the JEE, and with muitisectorai capacity building re[ated to International Heaith Regu[ations’ core capacities (e.g., points ofentry, risk communication and community engagement). In addition, WHO wi[i aiso support the impiementation of the necessary activities highiighted in the Catastrophe medicine action ptan (under deveiopment). Furthermore, WHO wili support the Government in multisectorai capacity buiiding on mentat heaith and psychosociai support, through capacity buiiding to imp[ement the mhGAP humanitarian intervention tooL among others. Fig. 1 beiow sets out a high-level theory of change which is further detaiied in Annex 1. 11  ___ (JO) fl - o 1. Figurel.Theoryofchange ‘ 0 4.’ w 4’ 4’ Strategic Priority 1 Strategic Pnority 2 Strategic Priority 3 Strategic Priority 4 0 u Heaith promoting Promoting mentai heaith Access, financiai protection Emergency preparedness environment and choices and access and quaiity and qua(ityofcare ofmental heaith services across the iifespan 2 -J O Evaiuation and O Promote mental heaith O improved affordabiiity O Deveiopment and impiementation of the across the iifespan in accessingto care, impiementation of AicohoL poiicy evaluation medicines and medical a national action and impiementation O Primary heaith-care and devices pian based on the community workers recommendations of the O Evaluation and empowered and O Quaiityofcareimproved JEE and sustained O impiementation of the equipped with toois and Tobacco/nicotine policy capacityto promote O Estabiish muLtisectoral (1) 19 O Deveiopment and impiementation ofa mental heaith and to support peopie with mentai heaith iliness O Capacity of policy makers strengthened to guide evidence approachesto buiiding international Heaith Regulations’ core n nutrition and physicai informed decisions and capacities (D activity action pian O Quaiityofservices to iead poiicy processes improved for peopie with effectiveiy e.g., heaith O impiementation of O Supporton buiiding mental health iilness care financing, evidence activities highiighted in capacities of national informed poiicy-making the Catastrophe medicine authorities on action pian environmental heaith O Capacitybuiiding O increase in heaith iiteracy to imp(ement the mhGAP humanitarian intervention tool t 0 Acceierated resource Agiie and responsive Staffengagement Risk informed mobilization business model programming 12 CM ( D II — 4. Implementing Arrangements To ensure successfu( imp[ementation of the strategic direction of the CCS and to achieve meaningfu[ health impact, co1Iaboraton at every level wiH be of pivotal importance. WHO wH! actively engage with the MoSA, the Nationa[ Institute for Health Development, the HeaLth Board, EHIF, nongovernment1 organizations and university and research agencies to develop new efficient and effective ways of working; to prioritize a small number of activities with Large impact; and to ensure that the reduction of health inequalities stays at the heart of every activity. The WHO Country Office in Estonia wiLL be Leading the work at Country Level, with a possib[e additional National Professional OffiCer in the next biennium. WHO’s Regiona[ OffiCe for Europe and WHO headquarters wi([ provide necessary support and resources to faCilitate effeCtive deLivery as appropriate and when needed. The CCS wi[[Coverthree bienniums and wil[ be imp[emented through the biennialworkplans deve(oped for eaCh ofthese three bienniums (2024—2025, 2026—2027 and 2028—2029). The monitoring of workplan impiementation wiH enable the reporting of progress in impLementing the CCS. 5. Monitoring and Evaluation The imptementation of the CCS wil[ be monitored through regular meetings between the MoSA and the WHO Country OffiCe. Regular foLlow up meetings wi([ a[so ensure that strategiC priorities Continue to be aligned with national health priorities and plans. AnnuaL, mid-term and final evaluation aCtivities wil[ be Linked to existing national reviews and evatuation processes of Estonia’s NHP. In addition, the below indiCators (Tab[e 1) developed with and agreed by Estonia’s Government wiIL serve as a basis to measure Country impaCt. 1 14 Tabie 1. Country impact/results framework Indicator Indicator Baseline Target . DataSource Alignment PRIORITY 1: Hea(th-promoting environment and choices Indicatorl.1: 2019 2030 NHPgoaL NationalAlcohoL Pure alcohol 10.4 9.5 Yearbook Data consumedin Iiters per capita bythosez 15 years Indicator 1.2: 2019 2030 NHP goal National Health Percentageof 12.9%female 10%fema[e Behaviorsurvey daily smokers 23.4% mate 15% ma(e amongfemales/ ma(es Indicator 1.3: 201812019 2030 NHP goa[ WHO European Percentage school year 21% Childhood offirstgrade 26.5% Obesity students who are SurveiL[ance overweight or Initiative obese PRIORITV2: Promotingmentathea(th and accessand qualityof mentatheatthservices acrossthe lifespan Indicator 2019 2030 NHPgoa[ Estonian 2.1: Suicides 14.6 10.5 Statistics per 100 000 population Indicator2.2: 2019 2030 NHPgoaI NationalMental Percentage 9% 7% HealthSurvey of 16—64-year old’s who have been diagnosed ortreated for depression in the Iast 12 months 1 15 (f Di C . Table 1. contd. o -‘ PRIORITY 3: Ensuring financia( protection, access and qua(ity of care o g. Indicator3.1: 2019 2030 NHPgoaI Nationallnstitute Percentageof 95% 100% for Health the poputation Development who has health insurance coverage Indicator3.2: 2019 2030 NHPgoaL WHOGIobaL Percentage of 23.9% 15% Health out-of-pocket Expenditure payments oftotal Database health spending Indicator 2019 2030 NHPgoaL National Institute 3.4: Number 623 845 for Hea[th of nurses Development per 100 000 population Indicator3.5: 2019 2030 NHPgoaL EstonianHealth Influenza 10.2% 40%. Board vaccination coverage among those? 65 years PRIORITY 4: Increasing emergency preparedness Indicator4.1: 2022 2030 continuous N/A WHO SPAR rating — 75 improvement aH capacities average Indicator4.2: 2022 2030 continuous N/A WHO SPARrating— 53 improvement points ofentry and border health Notes: N/A: not applicable; SPAR: State Party Sef-Assessment Annual Reporting 16  :1 6. References’ nO 1 1. Eurostat (2022). Country Facts. Brussels: Eu rostat (https://ec.eu ropa.eu/eurostat/cache/cou ntryfacts/#). 2. Government of Estonia (2021). Estonia 2035. Taiiinn: Government of Estonia. (https://vaIitsus.ee/e/ media/3926/downioad). 3. Laidra K, Reile R, Havik M, Leinsalu M, Murd C, Tuiviste J, et ai. Estonian Nationat Mental Heaith Study: Design and methods for a registry-Iinked longitudinal survey. Brain Behav. 2023;13(8):e3106. doi:10.1002/ brb3.3 106. 4. OECD (2021). Estonia: Country Health Profiie 2021. In: OECD [websitei. Paris: OECD (https://www.oecd.org/ estonia/estonia-country-hea Lth-profiie-2021-a6clcaa5-en.htm). 5. OECD (2022). OECD Economic Surveys: Estonia 2022. Paris: OECD (https://www.oecd-iiibrary.org/ economics/oecd-economic-surveys-estonia-2022•3bb8f6c5-en). 6. OECD (2023). Estonia Economic Snapshot. In: OECD [website]. Paris: OECD (https://www.oecd.org/ economy/estonia-economic-snapshot/) 7. Sotsiaalministeerium [Sociai Ministryj (2014a). Aikohoilpoliitika roheline raamat [Aicohoi Poiicy Green Paperi. Tailinn: Government of Estonia (https://www.tai.ee/sites/defauit/files/2021-04/a(kohoiipoliitika roheiine•raamat.pdf) (in Estonian). 8. Sotsiaalministeerium {Social Ministry] (2014b). Tubakapoliitika Roheline Raamat [Tobacco Poiicy Green Paperi. TaLiinn: Government of Estonia (https://www.sm.ee/media/3052/downioad) (in Estonian). 9. Sotsiaalministeerium [Sociai Ministryj (2020a). National Heaith Pian 2020-2030. Taiiinn: Government of Estonia (https://www.sm.ee/media/3054/download). 10. Sotsiaalministeerium [Sociai Ministry] (2020b). Vaimse tervise roheline raamat [The Green Paper on Mental I-Iealth]. Tailin: Government of Estonia https://www.sm.ee/sites/defauit/files/news-related-fiies/ vaimse•tervise•roheiine•raamat•0.pdf) (in Estonian). 11. Sotsiaalministeerium [Social MinistryJ (2021a). Eesti Narkopo(iitika Aastani 2030 [Estonian drug poiicy until 2030]. Taliinn: Government of Estonia (https://www.siseministeerium.ee/media/696/downioad) (in Estonian). 12. Sotsiaalministeerium [Social Ministryi (2021b). Vähitörje tegevuskava 2021—2030 [Cancer controi action pian 2021—2030]. Tailin: Government of Estonia (https://tai.ee/sites/defauit/fiies/2021-05/ V%C3%A4hit%C3%Bsrje•tegevuskava•2021%E2%80%932030.pdf) (1 n Estonia n). 1 Ali weblinks were acce5sed on the 4 December 2023 1 18 13. Sotsiaalministeerium [Social Ministry] (2022). Vaimse tervise tegevuskava 2023—2026 [Mental Heaith Action Pian 2023—2026]. Taliinn: Government of Estonia (https://www.sm.ee/media/2999/downioad) (in Estonian). 14. Sotsiaalministeerium [Sodat Ministry] (2023). Ravimipoliitika 2030 [Medicines policy 2030]. TaIiinn: Government of Estonia (https://sm.ee/media/2771/downLoad) (in Estonian). 15. Statistic Estonia (2023). Population. In: Statistic Estonia [website]. Tailinn: Government of Estonia (https:// www.stat.ee/en/find-statistics/statistics-theme/popuiation/). 16. Tervisekassa (2021). Arengukava 2022—2025 [Deveiopment pian 2022—2025]. Taliinn: Tervisekassa (https:// www.tervisekassa.ee/tervisekassa/strateegiad-ja-arengusuunad/tervisekassa-arengukavad) (in Estonian). 17. WHO (2016). Problem management plus (PM+): individual psychologicai help for aduits impaired by distress in communities exposed to adversity. Geneva: World Health Organization (https://www.who.int/ publications/i/item/WHO-MSD-MER-16.2). 18. WHO (2019). QualityRights materiais for training, guidance and transformation. Geneva: Worid HeaLth Organization (https://www.who.int/pubLications/i/item/who-qualityrights-guidance-and-training-toois). 19. WHO (2023a). Health Expenditure Profile. in: Giobal Health Expenditure Database [database]. Geneva: World Heaith Organization (https://apps.who.int/n ha/database/cou ntry•profiie/I ndex/en). 20. WHO (2023b). Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. Geneva: World Health Organization (https://www.who.int/publications/i/ item/9789240084278). 21. Worid Bank (2023a). Country Classification. In: Worid Bank Country and Lending Groups [database]. New York: World Bank (World Bank Country and Lending Groups World Bank Data Help Desk). — 22. World Bank (2023b). Worldwide Governance indicators. in: Databank [database]. New York: World Bank (https://databa nk.woridba nk.org/source/wortdwide-governance-indicators). 23. World Bank (2023c). Gini index Estonia. In: The World Bank, data [database]. New York: World Bank — (https://data.worldbank.org/indicator/Sl .POV.GINI?Iocations=EE). 1 19 Annex 1: Theory ofchange The below strategic priorities were identified following a series of consultations and d iscussions with the Ministry of SociaL Affairs of Estonia and other stakeholders and are based on critical analysis of the country’s needs and WHO’s comparative advantage in addressing those needs. Tab[e Al 15 an extension of Fig. 1 in the main document and sets out a more detailed description of the theory of change of the Country Cooperation Strategy (CCS) and indicates how the fourstrategic priorities of the CCS, with corresponding strategic deliverabies, key activities and indicators, wi[1 contribute to the de[ivery of national health targets. TabLeAl. The overail theory of change of the CCS Strategic Priority Strategic Key activitiesl Outcome-Ievel (and the health deliverable interventions indicators’ chatlenges they address) STRATEGIC PRIORITY 1 HEALTH PROMOTING ENVIRONMENTAND CI-IOICES 1.Heatth-promoting Evaluation and O Providingadvice and conducting O Pure aicohoi environment and choices impiementation of assessments of the current situation consumed in Liters the aicohoi poiicy and impact of poticies/activiti per capita bythose Toaddresshighratesof ?15 years behavioral risk factors O Percentage ofdaiiy that contribute to Evaiuation and O Assessing the current situation and smokers among premature mortatity and impiementation of giving advice on poticies/activities to females/males morbidity the tobacco/nicotine improve the poiicy measures poiicy O Percentage offirst grade students who are Deveiopment and O Supporting the deveiopment and overweight or impiementation of impiementation ofthe nutrition and obese the nutrition and physicai activity action pian: food physical activity reformulation, food taxes, front of action pian package Iabeiling and marketing O Conducting studies to evaluate the current situation and impact of poticies/activities and giving poiicy advice Support the O Increasing capacity reiated capacity buiiding of to climate change inciuding national authorities noncommunicabie diseases on environmental O Increasingcapacityofenvironmentai heaith hea!th Increase heaith O Supporting the deveiopment and iiteracy impiementation of nationai heaith [teracy guidance 21  _ CM ( (D Tabte Al contd. ao -‘ mfl Strategic Priority Strategic Key activitiesl Outcome-Levet (jO -Olo (and the health deLiverabLe b interventions indicators’ o chaLtenges they address) — 0 STRATEGIC PRIORITY 2: PROMOTING MENTAL HEALTH TO IMPROVE ACCESS TO AND T HE QUALITY OF MENTAL HEALTH SERVICES ACROSS THE LIFESPAN 2. Promoting mentat Promote mental O Impiementation of the nationai O Pure aicohoi health and access and heaith across the suicide prevention action pian consumed in iiters quality of mentat hea(th iifespan O Impiementation of nationai mentai per capita bythose services across the heaith action pian with a speciai z15 years Lifespan focus on chiid and youth mentai O Percentage ofdaiiy heaith and on interventions and best smokers among To address high rates of practices for oider peopie femaies/maies mentat health prob(ems O Conductinganaiysisto know the Percentage that aLso contribute to a mentai heaith reiated costs for offirst grade high suicide rate Estonian society students who are overweight or obese Primary heaith care O Supporting the impiementation of and community different WHO toois, e.g., mhGAP workers empowered toois in primary heaith care and and equipped with communities (mhGAP community toois and capacity tooikit, mhGAP intervention guide) to promote mentai O Supporting the impiementation ofa heaith and to nationai mentai heaith action pian support peopie with through WHO toois mentai heaith iiiness Quaiity ofservices O Impiementing the WHO mentai improved for peopie heaith quarty rights approach and with mentai heaith trainings in the heaith and sociai iiiness sector and giving poiicy advice on sustainabiy maintaining the nationai system -•J. 4 1 22 TableAl contd. Strategic Priority Strategic Key activitiesl Outcome-levet (and the health deliverable b interventions indicators’ chaltenges they address) STRATEGIC PRIORITY 3: ACCESS, FINANCIAL PROTECTION AND QUALITY OF CARE 3.Ensuring financiai Improved O Supporting with anaiysis and poiicy O Percentage protection, access and affordabiiity in advke on widening the heaith of popuiation quality ofcare accessing care, insurance coverage and maintaining who has heaith medcines and sustainabie heaith-care financing insurance coverage To address high out medicai devices O Giving advice and anaiysingthe O Percentageof of-pocket payments, situation on decreasingout-of out-of-pocket financial protection, pocket payments and to increasing payments oftotai unmet need for medical financiai protection heaith spending care and scarcity of financial and human O Supporting the impiementation O Numberofnurses and evaiuation ofevidence-based per 100 000 resources that ali hinder tubercuiosis, HIV and hepatitis C popuiation the access and quality of services interventions O infiuenza O Giving advice for the deveiopment vaccination and impiementation ofthe human coverage among resources for heaith action pian 65 years and oider O Supporting the impiementation of the nationai medicines poiicy by focusing on access to medicines (avaiiabiiity and affordabiiity (prices and co-payments)). O Heipingto deveiop and impiement new services that focus on prevention and lifestyle improvements, e.g., nutrition and physicai activity counseiiing O Anaiysing heaith system governance and performance and advising on how to strengthen the current system O Supporting the deveiopment and impiementation of the immunization action pian to ncrease vaccination across the iife-course, with a speciai focus on infiuenza vaccination Quaiity of care O Maintaining the capacity to deveiop improved and chnicai guideiines and heipingto susta i ned deveiop the methodoiogy O Supporting the deveiopment and impiementation of the antimicrobiai resistance One Heaith action pian, infection prevention and contro( action pian and patientsafetyaction pian Capacity of O Maintaining the capacity to poiicy-makers impiement WHO too(s for evidence strengthened to informed poiicy-making and the guide evidence capacity of poiicy-makers to iead informed decisions pohcy processes effectiveiy and and to Iead based on evidence (e.g. trainings, porcy processes webinars and workshops) effectiveiy, e.g., O Offering poiicy-makers and key heaith-care stakehoiders capacity-buiiding financing and opportunities on specific heaith or evidence informed heaith system reiated topics (e.g. poiicy-making through nationai and internationai webinars, workshops, seminars, conferences and trainings) 1 23 1•,) fl Table Al contd. ‘< < 0 Strategic Priority Strategic Key activitiesl Outcome-tevel Lfl (and the heaLth deliverableb interventions indicators’ chaflenges they address) — D) 0 STRATEGIC PRIORITY 4: EM ERGENCY PREPAREDNESS 4. Increasing emergency Deveiopment and O Consuitations and broader engage SPAR rating ali— preparedness impiementation of ment on the deveiopment and capacities average a nationai action impiementation of national heaith To increase emergency pLan based on the security action pian based on JEE SPARrating— preparedness to recommendations recommendations points of entry and be better prepared ofthe JEE O Reviewing and Estabiishing mech border heaith for future health anisms for the impiementation of emergencies Estabiish muiti catastrophe medicineaction pian sectorai approach (currentiy underdeveiopment) esto buiiding O Anaiysing the situation and pro International Heaith viding technicai advice on how to Reguiations’ core ensure access to medicines, medicai capacities devices, and biood products in emergencies impiementation of O Muitisectorai capacity buiiding activities highiight reiated to International Heaith Reg ed in the catastro ulations’ core capacities (e.g. points phe medicine action of entry, risk communication and pian community engagement, etc.) O Assessing the current situation and giving advice on poiicies/activities to improve the pohcy measures O Supporting the development and impiementation of the nutrition and physicai activity action pian: food reformuiation, food taxes, front of package iabeiiing and marketing O Conducting studies to evaiuate the currentsituation and impactof poiicies/activities and giving poiicy advice Support muitisec O Supporting Estonia with mentai torai capacity build heaith and psychosociai support ing on mental heaith coordination eg., poiicy advice and psychosociai about reievant sustainabie activities, support monitoring and evaiuation of impie mented activities and muitisectorai stakehoider capacity buiiding O Advising and guiding the impiemen tation of the mhGAP humanitarian intervention tooi inciuding its reiat ed capacity buiiding Strategic shiftsd System based approach — Working beyond heaith — Strategic communication Risks and assumptions Lack of sufficient financing iack of poiiticai commitment iack of/turnover of human — — resources pubiic heaith emergencies partnerships are not ieveraged inabiiity to measure impact — — — Enablers Acceierated resource mobiiization agiie and responsive business modei — — risk informed programming staff engagement — Notes: JEE: Joint Externai Evaiuation; mhGAP: Mentai Heaith Gap Action Programme; SPAR: State Party Seif-AssessmentAnnuai Reporting. Identified based on reievant background documents (GPW13, NHPSP, UNSDCF etc.), country context anaiysis, stakehoider pohcy diaiogue and prioritization High ievei deiiverabies (outcomes), preferabiy 3—5 per Strategic Priority. Use the Thirteenth Generai Programme of Work’ Resuits Framework as reference to identify 2—3 indicators directiy/indirectiy iinked to the strategic dehverabies. Set baseline and targets based on national targets. Outiine the key changes/approaches adopted to achieve the deliverabies. Thirteenth geriera( programme ot work, 2019—2023: promote health, keep the world safe, serve the vuinerahte. Geneva: World Health Organization; 2019 )https://www.who.int/publications/i/item/thirteenth-general-programme-of-work-2019-2023, access date 6 December 2023). 1 24