According to Jesse, TAI is a classical institute of public health, which complements academic research with a more practical approach. "All countries have such institutions," she said when describing the institute's current function.

"TAI is also connected to support for policymaking," she continued. "In Estonia it has played a huge role in keeping HIV and tuberculosis under control. TAI  also offers drug prevention services as well as methadone[-based opioid] substitution treatment and needle exchanges. These are services where medical institutions aren't fighting for Health Insurance Fund contracts, which is why these services need more support. Our society, however, needs addicts to get treatment."

What was botched in the state reform intending to merge various Estonian healthcare institutions, Jesse explained, is the fact that institution directors were told in mid-January, without any prior discussion whatsoever, what the solution would be. Then, a month later, were told that the objective was to integrate the country's social and healthcare services, and that the solution would be merging the State Agency of Medicines and the Health Board and closing down TAI.

"This does not support the goal stated after the fact," she said. "Furthermore, everything is being done within a very narrow timeframe to ensure that it gets done before the arrival of a new budget and a new minister."

Institutions that already have to act to ensure we can cope with COVID without closing down society are also now being saddled with the obligation to act in a fast timeframe, Jesse pointed out. "Add to that now the caring for the health of the refugees [from Ukraine], which the Health Insurance Board and Health Board are also dealing with," she added.

Asked whether the announced merger of healthcare institutions is a bureaucratic or a political reform, Jesse replied that this is a bureaucratic and mechanical merger with the goal of simplifying things from the administration's perspective: it will mean fewer directors to communicate with.

"The risks are high when rushing," she said. "Regardless of the reform, it is taken into account that there will be opposition. I was working with these people nearly half a year ago; they were ready for changes. I know what changes were being prepared. The issue is that changes should be targeted, and thereafter executed."

If they rush now, they may end up going down the wrong road altogether and taking out the wrong hedge, she warned figuratively.

Degree of influence depends on specific minister

On the subject of ministers' influence on various social reforms, Jesse said that she has worked together with various ministers in the public sector, and how big of a role a minister or officials have will depend on who the minister is.

"At the same time, it is the role of officials to point out bottlenecks and solutions," she continued. "One example of a minister who came in with their own wishes is Eiki Nestor. Jevgeni Ossinovski as well, whose priorities were alcohol and HIV prevention, supporting the Gene Bank and the sustainability of healthcare funding. Some ministers aren't so clear in stating their priorities, or have stuck to what was agreed upon in the coalition agreement."

In terms of healthcare services, the transferring of TAI's functions to the Health Insurance Board may be justified, Jesse said, but only if the latter also takes on the handling of addiction-related issues as well.

"The question is, is the Health Insurance Board prepared to get involved in the promotion of local health, with softer measures that promote people's health?" the healthcare expert asked. "For example, is the Health Insurance Board prepared to provide feedback to the food processing industry regarding sugar in yogurt?"

Maris Jesse earned her MD from the University of Tartu and MSc degrees from the London School of Hygiene and Tropical Medicine and the London School of Economics and Political Science.

She has previously served as deputy secretary general for the Ministry of Social Affairs, director of the National Institute for Health Development (TAI), senior health specialist at the World Bank and managing director of the Estonian Health Insurance Fund.

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