Of Estonia's ministerial roles, all 16 of them, that of Health and Labour gets sidelined compared with more "glamorous" positions like defence, foreign affairs, finance, or justice.* It tends to get politicised around election time, often skewered by opponents for costing too much in taxation (via the health and unemployment insurance funds) yet paradoxically presiding over underfunded or ineffective systems.
This belies the role's significance. Far more multifaceted than many of the "plum jobs," it is one of three binomial ministerial roles (ie "the Minister of X and Y")**, but crucial to the running of the modern Estonia so often marketed internationally.
It was thus timely to catch up with Riina Sikkut — the second-newest minister, only starting work in May and being sworn in at the same time as Minister of Public Administration Janek Mäggi (Centre) — to tell us about the situation now, in the future, to provide practical info, as well as to correct some misconceptions about the Estonian health service.
Arriving at the newish so-called Superministry building on Suur Ameerika Street just south of Tallinn's city centre, I couldn't ignore the looming general election (Riina Sikkut's loyalties are to the Social Democratic Party, or SDE, one of three governmental coalition parties) and the concurrent jostling for position. How the somewhat charming and immensely likeable Ms Sikkut, by admission not a political figure, fits into that is harder to pin down.
Alcohol duties a political issue
She didn't come from the Riigikogu to the ministerial job back in May. Government ministers do not sit in the Riigikogu, but are often drawn from its ranks, with a substitute from the same party stepping into the breach; if a minister returns to the Riigikogu, the substitute has to make way, as happened when Urve Palo, also of the SDE, resigned as Minister of Entrepreneurship and Information Technology in August. But she has inherited to my mind something of a hornets' nest.
One of the most divisive recent issues, hikes in alcohol excise duties, are at a level now which, opponents say, is damaging the Estonian economy, driving trade south of the border to Latvian towns like Valka.
However, the excise duties on beers and wines as well as spirits are not the only culprit, says Ms Sikkut.
"The business model in Latvia is different; with bulk storage, less refrigeration, fewer salespeople and other differences, even with reduced excise duties, alcohol would still be cheaper there," she explains.
It appears the health of the nation for her trumps booze cruise custom.
"Our goal isn't simply to make alcohol cheaper, particularly when we have wages rising at around 5% per year," she continues.
Sticking to principles
This commitment to ideals is commendable but can make things difficult between now and the Riigikogu election in March. Whilst Centre is the most natural coalition partner, the Conservative People's Party of Estonia (EKRE), a party likely to be the big winner at the polls, has already declared SDE a pariah with whom it wouldn't do business. Ms Sikkut reciprocates: "We don't share any values on issues like freedoms or the status of minorities," she says.
But even without EKRE, if SDE finds itself in office again after March, with the Estonian political landscape as it is, whichever party makes up the third in the coalition (currently a spot occupied by the beleaguered Isamaa/Pro Patria) is likely to be free-market oriented. If SDE is to have its way, the other party will have to tone down more classically laissez-faire approaches, at least on health.
"We can't move away from our main policies on health; the solidarity-based healthcare system gives us the best value. We can't move away from that, and it's the same with alcohol and tobacco policy," Ms Sikkut says.
So much for politics. One "unusual selling point" which she can bring to the role is a solid background in the field, having done research on health policy before becoming a civil servant, advising on health issues. She was an obvious choice. So did Sikkut have her eye on the role beforehand?
"No, I didn't. I was always an SDE voter/supporter, but I didn't see myself in politics. At the same time, having a background in health policy, which is my favourite aspect of the role, meant I could hit the ground running when I started, as I had all the terminology, the way health services work, down''.
"My first degree was in public sector economics, and since I had a professor who covered health economics, I did a paper on the subject, covering areas like tobacco and excise policy, the value of life and so on."
A joint master's degree followed at the University of London, in conjunction with the London School of Hygiene and Tropical Medicine and the London School of Economics.
What if expats get sick?
Having an expert in a ministerial role, rather than a politico, also means I can't pass up the short time I have with the minister to clarify recurring questions on various expat social media forums, in summary: What should you do if you get sick?
"First off, emergency care is free for all; with the Europe-wide emergency agreement you would visit the emergency medical department in the same way as anywhere else. For less urgent cases, the Health Board [Estonian: "Terviseamet", the website is here — ed.] offers help with finding a family doctor (GP)," she says, conceding the site needs an overhaul, as we'll see.
A patient must be insured to get free primary, or GP, care; social taxation covers this. Since many expats are self-employed or run their own businesses, it is their responsibility to pay the social tax; others opt for private health insurance.
Social media forums do have their uses, the minister says. They reflect actual experiences, including in regard to specialists. From what I can see, this is true: "Where can I find a good [insert type of specialist]?" is almost as commonly asked as "Where can I find a good, English-speaking family doctor?".
Waiting lists criticisms
A recurring criticism of the Estonian healthcare system concerns waiting lists. This is appropriate in that independent Estonia's system was modelled on the UK's National Health Service (NHS); long waiting lists are one of many brickbats that get thrown at that authority too. This is an oversimplification, however.
"A heath service without any waiting lists would not be effective," says Ms Sikkut. This might seem counterintuitive at first, but there is a rationale there. Having doctors and nurses idling around, M*A*S*H*-style, until Radar O'Reilly announces the arrival of military helicopters ferrying the wounded, is not quite how it works most of the time.
"If there were no waiting lists, doctors and other medical personnel would be sitting around with nothing to do, which would be a hugely inefficient use of their time and very wasteful. In fact, we need to manage waiting lists effectively, triaging cases on how pressing they are. Many medical issues can indeed wait, whilst others cannot," she says.
The public has a role to play too. There were two cases during the long, hot summer of 2018 of people scheduled for operations (in Rakvere) who did not show up and gave no notice of their intentions, obviously a hugely irresponsible thing to do with the operation room and staff booked, while others wait for treatment.
A lot of the waiting lists' criticism is also simply hearsay, from those with no direct experience one way or another, the minister says.
On the way to a centralised, digital system
None of which is to say there aren't problems and areas which need significant improvement, she continues.
A centralised digital registration system, whilst in the works and piloted in the North Estonia Medical Centre (PERH) in Tallinn's Mustamäe District, is some way off from being rolled out nationally. Pushback against having a more transparent system, for whatever reason, is one factor here.
When the system goes live a year from now, according to Ms Sikkut, it should help reduce waiting lists as people can't register double appointments, enable cancelled appointments to be filled quickly, and give people a choice of providers, among other things. Currently, people wait longer for local treatment since it is too much effort to shop around for alternatives; a centralised registration system eliminates this practice. It will also include those private medical service providers who opt in.
Having an airport-style check-in system, where patients check in online 24 or 48 hours before treatment or lose the slot, is another idea which would help speed things along, the minister says.
The Estonian Health Insurance Fund (''Haigekassa'') also plans to divert funds in the fight to shorten waiting lists, Ms Sikkut says. Speaking of which, another common claim is that there are around 120,000 people in Estonia who don't have health insurance at all (ie almost 10% of the populace). Whilst it is true there are a lot of uninsured people out there, the minister says, the true picture is a little more complex.
"The oft-quoted statistic is that about 5-6% of the population is uninsured. Recent analysis from think tank Praxis gave us the figure of 120,000, which includes people who have never been insured during the past 11 years and those who have gaps in coverage due to irregular earnings. But it is difficult to identify homogeneous groups to the extent that we can change the law to widen coverage. The only somewhat homogeneous group being those who don't have continual earnings, such as artists and performers, seasonal agricultural workers, even construction workers to an extent, will have periods where they are uninsured because they are not earning at that time.
"For the most part, universal health coverage would be the only way to pick up the pieces. This is only really now on the table for debate in Estonia, however, due to preconceptions that everyone must pay their way — why should the person who doesn't work, or who drinks too much, be treated the same as the rest — it is a hard sell.
"At the same time the current system means that those without insurance, whilst they can get emergency treatment for free [as noted above — ed.], they can't get basic treatment with a GP on the same basis. It's illogical, not to mention inhumane, that people can't have things nipped in the bud early on, only to wait for an emergency which of course costs the state far more."
Gender, age gaps
In addition to the health and labour responsibilities, a third also falls under the minister's remit — she is effectively the equality minister, so questions about the gender pay gap are next.
"Whilst 15% of the gender pay gap can be explained in terms of more women being involved in traditionally lower-paid jobs such as teaching, more women taking time off with maternity leave or working part time and so on, that still leaves the 85% which has not clearly been explained. Clearly more work is needed; employing a woman because she might ask for 20% less, whilst providing short-term economic gains, is short-sighted. We need a situation in which we know what the value of labour is regardless of the gender or other characteristics of the employee."
The ministry is to conduct further analysis in the coming year, Ms Sikkut says, to ascertain what the other factors are. In any case, with four female ministers out of 16, and 27 MPs out of 101, or around 25% in both cases, there is room for setting an example at the national political level too.
"It should be 50-50, but not just in terms of gender; there should be proportionality in nationality, ethnicity and so on. Estonian politicians are not on average as young as they used to be in the 90s, but there is still a lot of work to be done in getting older people more plugged into society and encouraging active ageing."
Regarding demographics, the gender wage gap, notoriously high in many post-Soviet/CEE countries, with women often living over a decade longer than men, is still an issue, though a narrowing one Estonia at least.
"The gap is still big even though in general life expectancy in Estonia has been going up. In fact, it has grown fastest out of the EU 28 in recent years," she says.
The statistic varies greatly by region, educational level, income bracket, type of occupation etc., Ms Sikkut says. Since more women have higher education than men, plus men tend to be employed in riskier jobs, this further accounts for the continued disparity.
Turning to the "labour" part of the job title, Peep Peterson, head of the Estonian Unemployment Insurance Fund (Töötukassa) has said that the €825 million reserves the fund holds would not see Estonia through the next crash. Is he right and what are the solutions?
"Yes, he's right. Whatever form the crash initially takes — be it in the banking, or construction or real estate sectors, the labour market is always going to be the first to be hit with lay-offs etc. This costs money on its own as long-term unemployment starts to supersede the kind of short term cover needed when times are good, but there is a lot more to the fund than just a piggy bank. Many people who are unemployed can get training, or retraining, based on the fund; a recent development as of last year has been that people with higher risk of unemployment (people who have out-dated skills, are older, or have reduced capacity to work), currently in employment can also apply for training to update their skills, for instance in IT."
While this may turn crisis into opportunity, it still costs money. It appears Ms Sikkut has the answer to maintaining the solidarity-based healthcare in the face of threats from Reform and other parties who champion the free market and personal responsibility for health, however: "Health insurance keeps tax morale higher, acts as an incentive. Whereas people struggle to make the connection between, say, current deductions and future pension payments, health is something less abstract which everyone can grasp the importance of. But the aim of social tax and health insurance is not to keep us paying taxes. And current healthcare financing lasts us for the next six to eight years. In that time we need to find a long-term solution for our health financing. One option being to untie the social tax contributions from getting insurance coverage".
Educating the public
Nonetheless, greater education is required to raise the role and awareness of primary and GP care amongst the home population, leave alone expats and recent arrivals. The concept of speciality care is ingrained in Estonia, presumably harking back to the old system before independence, but it can lead to farcical cases of people going to a specialist to get their blood pressure checked or when they have a cold, the minister explains.
More education is also needed to iron out other problems noted above, such as missing appointments, knowing where to turn to get help, issues of mental health, and to help solve the uninsured problem. For instance, many parents are unaware that when a child turns three, the family is no longer covered if the parent(s) stay at home rather than returning to work. Education in HIV prevalence is needed too, the minister says — whilst the earlier, drug use-related epidemic is under control, there are still a couple of hundred new cases per year, often older, non-drug-using people; others are not taking their anti-retroviral drugs as needed, which is also worrying, the minister says.
Never going to be perfect
So far as newcomers to Estonia go, a lot of work is needed there too.
"We're saying come and work in Estonia, with all these high-skilled IT jobs or opportunities to work for a startup, or even start your own, but we're not prepared well in other areas. Education is one, it can be difficult to find schools for those who are arriving with children, but with health it's definitely still the case that we're lagging behind. Most doctors can speak English [a repeated request on the expat forums — ed.] but when it comes to other languages, it's less rosy, although there are even two doctors here who speak Mandarin."
"The Health Board site is still not the most user-friendly — I've tested it myself — but we're working hard with the board as well as with the Estonian Society of Family Doctors to get a portal going with easier to find info and other languages."
Ultimately, perfection in the healthcare system, not to mention labour issues, is probably not for this life. The NHS is a continual target for both valid and invalid reasons; there seems no reason why the Töötukassa wouldn't continue to be too. The same goes for the US system which, despite popularly being viewed as a largely a privatised system, in fact sees the bulk of treatment going via the Medicare/Medicaid state and federal systems.
Rather than pinning everything on ideals, it seems that a certain amount of pragmatism is needed, according to Ms Sikkut
"A health system should answer the needs of the population, including what type and level of service they want, and how much data, such as genetic information, they are willing to share, rather than a one-size-fits-all approach," she says.
Labour is an even harder target to pin down in many ways; unemployment is currently low in Estonia, but the next global crash could hobble many sectors as well as more vulnerable regions of Estonia, principally in the east and southeast. However, people get sick regardless of the economy; epidemics can happen in good economic times and bad.
The role of Minister for Health and Labour is likely to bring many more challenges in future, though Ms Sikkut certainly appears a good bet and a highly competent individual. I started the job at ERR five days after Riina Sikkut started at the ministry; hopefully we'll both be there after the March elections. A wholesale change or sweeping away of the underpinnings of the system may exacerbate the very chaos which parties like Reform are constantly lamenting.
*In fact there are 14 Government ministries and 16 Ministers, as four of the ministers come under the auspices of two ministries. For example, both Riina Sikkut's role and that of Minister of Social Protection (Kaia Iva, Pro Patria) are under the Ministry of Social Affairs' jurisdiction.
** Minster of Economic Affairs and Infrastructure (Kadri Simson, Centre) and Minister of Education and Research (Mailis Reps, Centre) are the other two.
Editor: Aili Vahtla