Tiiu, who lives in Southern Estonia, takes care of her husband Wiktor who needs different medications to treat his cardiovascular disease, diabetes and psoriasis. He takes sixtablets in the morning and two in the evening, plus ointments and creams for the skin. Both Tiiu and Wiktor are pensioners and had
previously considered the out-ofpocket costs for their medicines to be significant, despite a subsidy from the government and being eligible for additional reimbursement owing to Wiktor’s high prescription costs. Tiiu and Wiktor had never applied for additional reimbursement because they did not know it existed. They may have been entitled to that benefit for years.

"Last year it was such a pleasant surprise when I went to collect the repeat prescriptions at the pharmacy and the pharmacist informed me that because the cumulative amount of co- payments I had paid so far this year exceeded 100 euros I now had to pay much less than I thought. The new mechanism makes it very comfortable and simple,” said Tiiu.

All patients in Estonia expect to make a co-payment towards their prescriptions at pharmacies. However, before 2018, the system left some of the poorest and oldest people in the population having to pay significant amounts to obtain the medicines they needed. Most patients had to pay a substantial percentage of their prescription costs and only received additional reimbursement if their co-payments exceeded 300 euros a year; also, an overly bureaucratic and complex process meant that although they were entitled to claim back some of the money they had paid for medicines, many patients often did not.

This all changed in 2018, when the government introduced a more people-centred approach that makes paying for prescriptions simpler and cheaper for the patient. Affordability – ensuring people can access health services without suffering financial hardship – is a crucial aspect of universal health coverage (UHC). Today in Estonia, all patients can benefit from a seamless and more protective payment system for prescribed medicines. When their spending on prescriptions in one year.

exceeds 100 euros, the government immediately covers half of any further costs until patients have paid 300 euros in total, after which the government pays almost all (90%) of any further costs. Patients do not have to apply for this benefit and wait to be reimbursed, as in the past; it now happens automatically and on the spot, through the pharmacy’s information technology system.

Out of pocket payments for prescription medicines have significantly declined thanks to the improved system. The figures speak for themselves. In 2017 only 3, 000 people benefited from additional reimbursement, but that rose to 134, 000 people in 2018. The number of people spending more than €250 annually on outpatient prescriptions fell dramatically from 24, 000 in 2017 (2.8% of the population) to 1 000 in 2018 (0.1%).

Step change for UHC

Although Estonia’s intention was to ensure affordable access to medicines, the previous complicated
co-payment system was actually failing those who needed it most. WHO has worked with the Government of Estonia over a number of years to help influence and ensure a smooth transformation process.

In 2010, the Health Insurance Fund and the Estonian Ministry of Health and Labour asked WHO to do an analysis of the financial sustainability of the Estonian health system. WHO interviewed 28 different health stakeholders to see how they understood the system’s sustainability and values and what stakeholders thought was most important to protect in the health system. Findings showed that financial protection for households was not very strong and needed to improve.

A more recent WHO analysis found that the extent of financial hardship in Estonia was quite high compared to many other EU countries. This was mainly driven by people having to pay out of pocket for outpatient medicines and experienced by people in poorer households. Over a period of years, WHO has gently advocated a fairer co-payment system that puts the patient’s perspective at the centre of the transformation and encouraged step-by-step progress towards UHC. The government understood that something needed to change and in 2018 took the lead to establish an improved co-payment system, which provides better protection for people facing relatively high out-of-pocket payments for medicines.

The improvements are in line with the ‘Tallinn Charter: Health Systems for Health and Wealth’; a powerful statement signed in 2008 by all European member states, WHO and other development partners. It promotes equity, solidarity, financial protection and health through health system performance monitoring, assessment and improvement. In 2018, to celebrate the Charter’s ten year anniversary, member states reaffirmed their commitment to its values and WHO presented the work on Estonia’s financial protection transformation, with Estonia’s Minister of Health and Labour present.

The experience of Estonia and other countries – documented in a new WHO study –demonstrates that although co-payments cause financial hardship, especially for poor people, it is possible to make medicines more accessible and affordable for everyone. Countries can take progressive steps towards UHC by putting people at the centre of health reforms, and designing systems to meet patients’ needs.

Making medicines affordable

The new process has transformed how people in Estonia access prescribed medicines, and is a good example of how progressive steps really do help a country to move towards UHC. Medical practitioners easily recognise the difference it can make to people’s health and wellbeing.

"It is a really positive step. On one hand, there’s a direct impact by reducing spending on medicines for patients, which leads to better adherence and reduces the risk of adverse events. On the other hand the automatic nature of the benefit is positive, especially considering the age of the main target group. It is very good that patients or their caregivers do not have to apply for the benefit or fill in separate forms; this saves time and transport costs,” said Diana Ingerainen, General Practitioner from Järveotsa Perearstikeskus, Estonia