Untreated illnesses will be reflected in the future in the loss of years of life and work of the working-age people, thereby directly affecting the overall functioning and coping of the state, the National Audit Office said. Healthcare administration can be improved upon, however, by establishing substantive cooperation between healthcare specialists and by appointing a party whose task it is to ensure that a child receives help at the right time.

The state has prescribed medical examinations at specific intervals for early discovery of illnesses. The audit indicated that children undergo medical examinations irregularly, depending on the age of the child. Children up to the age of 2 years old, of whom 85-93 percent underwent the family physician's medical examination with the prescribed frequency, undergo medical examinations the most.

Preschool-age children 3-6 years in age should undergo medical examinations at least once a year. That said, however, less than four percent of preschool-age children underwent medical examinations at that frequency. Over three years, half the children in this age group never underwent medical examinations, which mean that some children may be off the healthcare employee's radar entirely. Children undergo medical examinations least often when they are of school-age: just 8-20 percent of children underwent examinations, depending on their age.

Infrequency of medical examinations caused by multilpe factors

There are different reasons for why children do not undergo medical examinations, found the National Audit Office. One reason is that the Ministry of Social Affairs has not been able to effectively make people aware of the necessity of medical examinations. Many family physicians have also not paid separate attention to children's medical examinations. Due to poor awareness, parents are still widely of the mindset that going to the doctor is not necessary before the onset of an illness. Children of parents with this mindset tend to see a specialist too late — only once the health problem has already aggravated. As a result, treatment time extends, the risk of complications increases, the child is removed from active life and the monetary burden on the country's healthcare system increases.

In the opinion of the National Audit Office, it is also necessary to analyze whether or not the number of times prescribed for medical examinations is optimal or whether there are certain exaggerations.

The second bottleneck that impedes the early detection of health problems is the organization of school healthcare in Estonia. Because a school-age child spends a large part of their day in school, both health promotion and monitoring of health should be a part of school life for all children. The audit indicated that 14 schools lacked school healthcare services. The established requirement of one school nurse per 600 students was not complied with everywhere, i.e. approximately 34,000 school children did not have access to required school nurse care.

Many educational establishments also lack necessary academic advising specialists that would know how to detect problems, including mental disorders, and help the child. For example during the academic year of 2015/2016, less than third of the general education schools had a special education teacher or a school psychologist. Less than half of the schools have a speech therapist. Because academic advising specialists are generally unable to stand in for one another, children's health problems are not detected in many schools before they have already aggravated.

One reason for the lack of school nurses is due to the fact that the Estonian Health Insurance Fund finances school healthcare services for just 11 months out of the calendar year, i.e. the school nurse is only paid for 11 months of the year. At the same time, a nurse working in a hospital generally earns a higher wage and does so for all 12 months per year. Academic advising specialists have also pointed out that one reason for the lack of interest in the work are the low wages.

Because health problems are not detected or diagnosed on time, children are not directed to see a specialist where the child could get the necessary help. In cases where the health problem was detected and the child was sent on to see a specialist, the child did not always make it to see one.

The analysis carried out by the National Audit Office of Estonia indicated that in the year 2014, school nurses sent children needing medical care most frequently to see an opthamologist, dentist or family physician. In all, 48 percent of the children referred to see a specialist made it to an ophthalmologist's appointment, 65 percent to a dentist's appointment and 41 percent to a family physician's appointment. Thus, just half of the children sent to see a doctor in whom the school nurse had detected a health issue never made it to see one. The reasons for this were poor access to specialized medical care, insufficient exchange of information between specialists and parents as well as the lack of awareness and/or disregard among the latter.

Children often not receiving needed mental health-related help either

The National Audit Office, in cooperation with the Estonian Psychiatric Association, also analyzed the treatment of children suffering from eating disorders and activity and attention disorders who were receiving hospital treatment due to their health status.

The results of the analysis indicated that 32 percent of children had received medical care on time, including 29 percent of children suffering from activity and attention disorders and 37 percent of children suffering from eating disorders. As such, the problem was not diagnosed on time in two-thirds of cases. Due to late discovery, treatment commenced on average two years after the first documented symptoms.

The audit indicated that if a health problem was diagnosed and the child also mad it to see a doctor, he or she did not always receive medical care to the required extent. Among obese children, for example, over a period of four years, 30 percent of the target group received health services for two years, 8 percent for three years and 4 percent for all four years. Treating an obese child, however, presumes receiving regular healthcare in order to ensure the effectiveness of the treatment. One reason for irregular treatment was the lack of case management approach, i.e. there was no party in the system that would make sure that the child saw the required specialist. On the other hand, irregularity of treatment was also influenced by the careless attitudes on the part of parents with regard to compliance with with treatment schemes as well as lack of awareness regarding health behavior. First illness among obese children has increased by 54 percent over a period from 2006 to 2014.

In summary, the results of the audit indicated that the monitoring of children's health and the provision of health services was not functioning in a coordinated and patient-oriented manner.

In order to improve the organization of maintaining children's health and treatment, family medical care, school healthcare services, specialized medical care and academic advising services must be combined into a functioning and coordinated network in a more effective manner than currently. In doing so, a prerequisite for functioning is that the system includes a specialist serving as a case manager whose task is to continuously monitor whether or not a child is sent to see a healthcare provider and whether or not the child receives the required services. If necessary, the case organiser must draw the attention of the parent and/or child protection services to the fact that the child has not received one or another health service necessary for the child.

Auditor General: Onus on parent, but state must step in when needed

Commenting on the results of the audit, Auditor General of the National Audit Office Alar Karis said , that "Liability for the welfare and health of the child lies with the parent, but the state cannot allow for children whose parents are unable to or do not know how to care for the health of their children themselves to be left without attention or help. For example, the number of irresponsible parents who have refused to vaccinate their children has grown, endangering both the health and life of their child, and at the same time putting the health of other children with whom the unvaccinated child comes into contact in risk."

According to Karis, in order to prevent health risks from realizing and to better manage health problems, attention has to be paid to the health of children already from the moment of birth. "This will be possible first and foremost by way of preventing illnesses through medical examinations and vaccinations, but also through promoting health by teaching both children and parents how to live a healthy lifestyle," he added.

According to the data provided by Statistics Estonia, around 258,000 children up to 18 years of age were living in Estonia in 2015, constituting 20 percent of the population. Over the past 10 years, the total number of children living in th country has decreased by nearly 30,500 children or by about 11 percent.