Public health reforms in Estonia: impact on the health of the population

Introduction

The health of the population has worsened in most countries in central and eastern Europe during the transition period, but little has been written about the reforms in the field of public health during this time, and little evidence has been presented on the links between these reforms and the health of the population.

We describe public health reforms in Estonia, focusing on the institutional structure, the reform rationale, the specific proposals and reform processes, the achievements and limitations, and the wider impact of the reforms.1 To describe trends in the health of the population, we use life expectancy, infant mortality, rate of abortions per 100 live births, morbidity rates (tuberculosis, HIV, sexually transmitted diseases), and the level of individual risk factors (smoking, diet, alcohol consumption). The study is based mainly on an analysis of previously published reports and official statistics.

Institutional structure

After the political changes in the beginning of the 1990s, the importance of a population based approach to public health was recognised in Estonia, and the understanding and application of the concept of health promotion became more comprehensive.2^–4

In 1993 the Ministry of Social Affairs was established and included a Department of Public Health (fig 1, box 1), which was seen as a source of modern health promotion in Estonia. Health promotion was introduced in the curriculum of medical and nursing training at the University of Tartu, and public health training for civil servants and teaching staff was started.4 5

The reform rationale

In general, democracy is considered to be good for the health of the population.6 When starting to build up a democratic society in the beginning of the 1990s, Estonia, like most other countries in central and eastern Europe, experienced a rapid worsening in population health indicators. …