The Praxis think tank reviewed the parties' health and welfare pledges and concluded that there is an unjustified lack of attention to health technologies, new funding sources and welfare issues in general, with labor shortages and waiting lists being recurring themes.

Since it was difficult to locate program commitments in these areas on the agendas of Parempoolsed and the Estonian United Left Party (EÜVP), the following analysis focuses on seven parties only.

On what topics are promises made?

The majority of political parties' health promises revolve around increasing access to health services. Estonia has the highest unmet medical demand in the European Union, owing primarily to lengthy treatment waiting lists. In this category, the Center Party has more than 20 promises, followed by Isamaa with 15, the Reform Party with 11 and the Social Democrats (SDE) with 10. The other parties have made fewer pledges, but some nonetheless.

Pledges are made to improve the accessibility and quality of health care services by, for example, investing in e-health solutions, health technology and the development of personalized medicine, or by boosting overall funding and decreasing wait times to guarantee accessibility.

At least one commitment has been made by each political party to alleviate the shortfall of health care personnel. The healthcare sector is plagued by chronic labor shortages (especially among nurses) and low employee compensation (e.g. care workers). The labor shortage and pay commitments address the shortage of medical personnel, training requirements and recruitment of new employees, in addition to the improvement of working conditions and compensation.

The prevention of various health problems is the second most popular political party promise, with only the Reform Party and Isamaa mentioning also disaster preparedness.

In general, the Estonian healthcare system does not place enough emphasis on preventive measures. Targeted actions (health screening, immunization, etc.) to prevent diseases and deaths are one component of preventive medicine. A number of electoral plans include emergency preparedness and tailored medicine as preventative measures.

Despite its growing importance, the use of health technologies and data in healthcare has received relatively little attention. Many political parties are completely silent on these topics.

Access to services promises are at the top of the list, with the Center Party making nine, Isamaa seven, and the Social Democrats, Eesti 200, and the Greens each making five. These are pledges to increase the availability of various welfare services (home services, support services, etc.) by increasing money, for example.

Staff pay in the healthcare sector is close to 70 percent of the Estonian average, indicative of a growing labor shortage. Negative reputation, poor working conditions, low pay and a severe workload all contribute to the sector's crisis. Only three of seven political parties (Centre, SDE and Isamaa) address labor shortage in the care industry in their electoral agendas.

The parties also address the issue of physical accessibility. This relates to inclusive design practices that make public buildings accessible for those with impairments and the elderly. Only three political parties include physical accessibility in their campaign pledges (SDE, the Greens and Eesti 200).

The National Audit Office of Estonia (Riigikontroll) has established that the health and welfare sectors do not operate as a unified body but are instead divided between several systems and between local and national levels. The analysis reviewed whether this issue was addressed.

Despite growing public interest in the issue, few election promises have been made on it. There is a significant potential for improving individual well-being through improved logistics of connected services and thus potential resource savings due to integration and better targeting of services.

Four parties have proposed new financing sources for welfare and healthcare, with Isamaa committing the most to shift funding sources.

For example, promises were made to increase state budget allocations for health coverage for the uninsured or equivalent persons, to seek additional ways to cover healthcare costs through savings and investments, and to promote the introduction of private health insurance products in addition to state health insurance.

Also, there were a few electoral promises that were not repeated but are noteworthy. For example, SDE propose addressing the issue of euthanasia, whereas the Greens advocate for the legalization of medical cannabis. Furthermore, Isamaa wants more financing for elite sports, SDE propose increased funding for elderly councils, and the Greens propose an increase in vegetarian food availability.

Compared to previous elections, mental health emerges as a distinct unifying category with a much higher profile.

In the health and welfare plan of Eesti 200, mental health receives the biggest proportion of pledges that stand in competition with the promises of Reform.

SDE and the Greens had the lowest percentage of mental health coverage. However, both the number and quality of mental health commitments vary substantially. For more information on the specific details of pledges, see the overview compiled by Peaasi.ee.

What happens to the promises?

It is necessary to assess whether the promises are measurable in order to understand whether they are later fulfilled.

A three-point scale was developed to assess measurability, with the highest scores given to promises that are clearly measurable and include a target level (marked in green in the figure).

The promises shown in yellow on the graph are, in principle, measurable under specific conditions, but there is no set target. With these, it is possible to figure out whether the promise has been partially fulfilled, but for a more thorough evaluation, indicators and targets should be defined.

The third category includes commitments that analysts believe are not measurable at all (marked in red in the figure).

To demonstrate "measurability," consider the following:

• Non-quantifiable promise: "We will pay more attention to health education and health days in schools." It is impossible to find out whether or not any attention was paid to this pledge.
• Conditional quantifiable promise: "We will reduce treatment wait times." There is no mention of how far they are to be reduced, but setting a target will help determine whether or not the promise has been met.
• Clearly quantifiable promise: "We will provide health insurance for all," or "We will provide a school psychologist in all schools."

Again, it is important to remember that promises that are clearly measurable are not always easy to deliver. Although the number of schools that employ a school psychologist can be counted, there may not be enough specialists in the country, for example, to have one in every school.

The Social Democrats have pledged the most percentage-based commitments, followed by the Center Party and Eesti 200.

Isamaa, who made the highest number of non-quantifiable promises, had the fewest quantifiable promises.

The majority of each party's pledges were non-quantifiable, with the exception of the Center Party, where slightly more than half of their pledges were to some extent quantifiable.

Are promises funded and how?

The initial objective of the election pledge analysis was to evaluate whether the programs addressed the sources of funding for the health and welfare pledges, i.e., whether they described where the financial means to fulfill the pledges would come from.

Due to the aging of the population and advancements in the medical field, it is common knowledge that health and social care financing issues become more pressing each year; therefore, it is essential to monitor whether the implementation of electoral promises is likely to result in sustainable financing of health and social care.

The analysis, however, revealed that none of the political parties mentioned the sources of funding for the financial cost of their election promises in the health and welfare programs.

Keep in mind, while evaluating the incremental cost of election commitments, those pledges that do not appear to have an added cost may be so imprecisely worded that the potential cost cannot be identified.

Several political parties, however, discussed how to change health and welfare funding and what additional sources of funding might be considered.

Isamaa underlined the need for greater private health insurance in a number of its electoral promises, while Reform also mentioned the employer's contribution to the cost of health care in relation to the prevention of work-related health risks.

The Greens favor public targeted investments into health care infrastructure, whilst SDE advocate for a nursing home investment support fund.

Re-use of promises

The extent to which the parties recycled promises made in previous elections was also reviewed.

We compared the wording of previous election promises with the current ones. Some pledges only partially overlapped in wording, so they were aligned with others that were fully overlapping, assuming that the meaning remained largely the same.

The Greens and EKRE have been the biggest re-users of their previous promises. The Eesti 200 less so, and Reform came out with entirely new promises.

There could be several reasons why political parties repeat their promises. It is understandable that opposition parties have not been able to realize their ideas and implement changes, and thus it is possible to bring old promises back on the table.

It is more difficult for coalition parties to justify why the previous government's promises have gone so far unfulfilled that they can be reintroduced unchanged. However, it is worth noting that all of the current members of the Riigikogu have been in coalition at least once and thus have had opportunities to influence policy-making.

Nonetheless, the country's circumstances are evolving, and several sectors may require more attention than they did four years ago, such as the growth of mental health as a top priority, crisis readiness concerns and an emphasis on prevention. The party's failure to handle these issues may indicate that health and welfare are not among their highest objectives.

In summary

The health and welfare pledges are mostly about access to both health and welfare services. There is also a strong emphasis on pledges related to the prevention of various health problems. There are parties with more than 50 different health and social issues pledges, and there are also parties with 15 or less. The number of pledges may show how important health and social issues are to the party. Almost half of the promises made by all parties are measurable.

Compared to the promises made in the state elections four years ago, a number of issues have become more important that weren't before: mental health has come to the fore, there is more talk of healthcare workforce shortages, and of integrating health and social care so that people have a single path through different interconnected services.

Mental health issues are proportionally most addressed by Reform and Eesti 200, less so by Isamaa, SDE and EKRE.

The proliferation of pledges does not, however, reflect the quality of the pledges, i.e. whether they are clearly formulated, well thought-out, measurable, with targets in place and with realistic sources of funding. However, to a certain extent, it does reflect the party's thinking on health and welfare and its consideration of the interests of different target groups.

The diversity of the pledges also reflects the extent to which health is viewed as more than just a health issue, with policies planned to support mental health and physical and social well-being in addition to physical illness treatment.

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