In healthcare, we entrust our lives and well-being to specialists. This trust is based on the assumption that the doctor, nurse or midwife we encounter is competent — not only at the moment they receive their diploma, but throughout their entire career. Unfortunately, a recent overview by the National Audit Office suggests that this assumption may not always hold true in Estonia.

A system that doesn't work

In Estonia, the assessment of healthcare professionals' competence is voluntary and carried out by professional and specialty associations at their own discretion. As a result, participation in such assessments remains minimal: as of early 2024, only 23 percent of practicing doctors, 62 percent of dentists and less than 10 percent of nurses and midwives held a valid competency certificate.

Many healthcare professionals undoubtedly pursue continuing education, but patients, employers and the state have no evidence-based assurance regarding the extent or quality of that training. What's more, in several medical specialties, it's not even possible to undergo a competency assessment at all, as the availability of such evaluations depends entirely on the capabilities and interest of the respective professional associations.

Criteria that do not compare

Where competency assessments do take place, they are not always substantively reliable or comparable. Professional and specialty associations apply a wide range of criteria, from training hours to supervision, research or evaluations of practical work. In some fields, the emphasis is understandably on hands-on experience — such as in surgery — but even the associations themselves recognize the need to better standardize these criteria.

It is also troubling that the absence of a competency certificate does not prevent someone from working in healthcare. If the Health Board suspects that a medical professional is not sufficiently competent to provide services, it has only limited options at its disposal, such as withholding certification or notifying the employer. However, there has so far been a lack of capacity to substantively address such cases.

Training that does not reach everyone

Healthcare service providers are legally obligated to ensure that their employees receive at least 60 hours of continuing education per year. Unfortunately, not all employees are able to participate. The obstacles are well known: a shortage of substitute staff, poor access to training in smaller centers and limited funding that fails to cover the full scope of training needs.

Even more problematic is the fact that no one knows exactly how many healthcare professionals miss out on training and no one is monitoring whether this critical aspect of professional development is actually being fulfilled.

Voluntariness not enough

The question of making competency assessments mandatory has been debated for years. Of the professional associations that responded to the National Audit Office's survey, 73 percent support making such assessments compulsory — on the condition that the state provides both financial and organizational support to develop the system. The Ministry of Social Affairs, on the other hand, considers making assessments mandatory to be complicated, citing the uneven capacity of associations and unclear boundaries of responsibility.

But as a society, we must ask: should a patient's trust and the quality of care depend on whether a specialty association has the resources to manage its own evaluation system? Can we afford to rely on the hope that all professionals will independently pursue sufficient development without oversight, direction or support?

Three directions from here

Competency assessment must become a natural part of a healthcare professional's development — not an added burden or a mere formality. Achieving this requires three things:

1. A unified and easy-to-manage system, for which the state is responsible.
2. Clear and comparable criteria, to be developed by the Ministry of Social Affairs in cooperation with professional associations.
3. A national digital platform and registry, to be led by the Health Board, through which the Health Insurance Fund can monitor service quality and ensure that funding is tied to competence.

In addition, the system must be linked to healthcare quality monitoring. Competency assessment cannot be an empty formality — it must be an integral part of safe and high-quality healthcare.

Trust must not be based on chance

If a healthcare professional can currently work for decades without ever having to prove their competence, then we have a system built more on faith than on evidence. And if we are unable to reliably assess and support the competence of our healthcare workers, we jeopardize the very foundation of the healthcare system: the patient's trust.

It's time to take the next step — not to increase bureaucracy, but to ensure that healthcare services in Estonia are high-quality and safe, regardless of time, place or the job title on a worker's name tag.

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