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Decentralisation of health promotion programs

Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
Agris Koppel, Ain Aaviksoo
Health Policy Issues: 
Public Health, Vergütung
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein ja nein nein ja nein nein


In 2005 a new strategy for prevention of cardiovascular diseases (CVD) was enforced. It is a first step toward centrally financed but regionally implemented national public health programs. A new management system was set up based on County Health Councils. Although targeting CVDs initially, the new initiative is foreseen as a stronghold for the implementation of future national public health programs.

Purpose of health policy or idea

The new strategy is aiming at improved heart health, combining the knowledge and action plans of various fields and county health councils. In every county health rooms are implemented where the population can get first information about public health problems and services.    

The purpose of the idea is to decentralise health promotion activities to meet better local needs and peculiarities. A County Health Council was set up by each county government (legally a subsidiary of central government), consisting of a broad spectrum of representatives from County Governor's offices, local governments, and stakeholder groups. The Council is funded mainly by the central government (Ministry of Social Affairs - MoSA). The core program and the list of specific measures under each intervention area (altogether 5 areas) are developed nationally, implementation and local/regional choice of interventions is managed by the Regional Councils.  

In the long run such organisation at the county level should become a permanent structure and form the basis for other public health programs besides the implementation of the CVD strategy.

Main points

Main objectives

Decentralized health promotion
The initiative is to link up the vacuum between national level public health planning and local grass-root level NGOs, which implement the activities but have little capacity and legitimacy for regional health policy development. 

Regionally improved access to and quality of public health information and services
Earlier the services were heavily dependant on the financial capacity of the municipality and the enthusiasm and professionalism of local health administrators. Therefore mainly inhabitants from the few largest municipalities and from the municipalities with enlightened administration had access, to some extent, to systematic public health services. Nationally established and funded County Health Councils are to guarantee services with adequate standard to all inhabitans.

Type of incentives

Core funding of County Health Council activities from state budget (through Ministry of Social Affairs).

Administrative reporting to central government and active feedback on progress to each county.

Groups affected

The Estonian population, local governments, NGOs


Characteristics of this policy

Innovationsgrad traditionell recht traditionell innovativ
Kontroversität unumstritten kaum umstritten kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering recht hoch sehr hoch
Übertragbarkeit sehr systemabhängig systemneutral systemneutral

The policy has been awaited for a long time. Implementation should proceed smoothly. The biggest challenge is to get the one-topic program work as an integrative link between all local/regional level public health interventions. The main link - County Health Council - has to prove itself as an operational body for local governance and not just as a clearing house for spending government money.

Political and economic background

Since 2001 there have been attempts to renew the the Public Health Act, which came into force in 1995. The law stipulates general responsibilities for local municipalities regarding population health, but offers very little support (including funding mechanisms) for executing this responsibility. Thus public health interventions have traditionally been seen as national responsibility only, even the local grass-root level NGOs have mainly been funded from the central budget.

A national program for CVD prevention has been developed since the beginning of the 21st century and lobby groups of different disease groups have had varying impact on government programs of different coalitions. The government that approved the program in 2005 had a CVD prevention program included in its coalition agreement, whereas the governments before them and after them (current government is in power since April 2005) did neither specify CVD prevention nor regional public health service development as their priority.

However, the implementation of the national strategy for CVD prevention is linked to the health policy statements of the Ministry of Social Affairs and the Estonian Health Insurance fund on "easy and timely access to health care services for all Estonian citizens". This implies the strong influence of the established bureaucracy on policy-making.

Complies with

EU regulations

The Estonian CVD strategy is referring to The Council of the European Union conclusion on ?Promoting Heart Health?, June 2, 2004.

Change based on an overall national health policy statement

The service implementation is in accordance with the general strategic goal of the Ministry of Social Affairs ? ?better health care service accessibility and quality?.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein ja nein nein ja nein nein

Origins of health policy idea

The idea is a follow-up of targeted funding of health promotion projects by the Estonian Health Insurance Fund (EHIF). At the end of 2001 an agreement between EHIF and the Ministry of Social Affairs was made that stated several priority areas for allocating EHIF earmarked funds for health promotion. The next step was to develop formal national programs on priority health areas - CVD, cancer, children, injuries. The "National strategy on heart health" was among the first that was approved by the government (2005) followed by the "Cancer prevention strategy" (2006).

Strategies have been approved by the government only if money for their implementation has been available. Precondition for money allocation is that   the specific programmes should be included in the formal agreements of a governing coalition.

In a way current programs, starting with the CVD strategy are substituting the shortcomings of the Public Health Act (1995). There have been attempts by civil servants and EHIF to initiate redrafting of the Public Health Act since 2001. Without poilitical backing, however, it has not happened so far.

Initiators of idea/main actors

  • Regierung

Approach of idea

The approach of the idea is described as:
renewed: It is renewed approach to the policy by which in 1997-2002 the competition of county level health promotion projects was executed also at regional level. The money was allocated by EHIF according to head count in a given county.

Stakeholder positions

In January 2005, the Government approved the "National strategy for heart health 2005-2020" by "cabinet decision" (the weakest legal document).

On the government side the Ministry of Social Affairs and its subisdiary National Institute for Health Development have been main promoters of the idea. As their role has been to balance different interests of stakeholders the initiative was long stalled by internal decision-making processes. Their support for the initiative is crucial.

The Ministry of Finance (MoF) opposed the initiative for a long time on the grounds that no clear financing strategy was proposed and that the initiative was not supported by other strategy documents that are used in the state budgetary process. MoF opposition is not unique to the current program: it can be attributed to the general conflict between vague and uncoordinated programs by sectoral ministries and MoF's robust fiscal strategy. The influence of the MoF is very strong especially before approving any new initiative by the government and later while deciding the annual budget for the strategy.

The Estonian Health Insurance Fund has been advocating a clear strategy by the state since 2001 as it has been the main funder of health promotion activities. However, without clear policy guidance it has mostly relied on expert opinions. EHIF is a strong player as it has specific earmarked funds for health promotion and disease prevention.

Medical professionals have supported the strategy because a big component of it is secondary prevention. The role of medical professionals is still quite strong as the local scientific basis is poor for any strategy building, so that expert opinions become the main argument.

Health promotion (heart health) professionals have been supportive of the general idea for a long time. However, the group of health promotion professionals does not unanimously support the final compromise version of the strategy due to competing interests about who should govern the funds that are allocated for implementation of the project. Indeed, there are also strong opponents among health promotion specialits.The final strategy version stipulates that coordination and implementation is executed by existing public agencies in a network manner and not by a separate third sector entity. The Estonian Heart Association even split during the development process of the strategy. In the end, their organisation has been left out of the Strategy Council due to open obstruction to the process.

County governments are generally supportive of any new concrete activity area as they lack any political autonomy, being just an outreach post of the central government. Their influence during the preparation of the strategy is among the weakest. However, once given the authority to govern the process they can have a much stronger role.

Local municipalities are in a sense objects of the new strategy - to bring health promotion services closer to citizens. The initiative should also fill in the vacuum left by the ambiguous regulation of the Public Health Act. However, as the governing role has been given to county governors' offices, which generally lack legitimacy and trust over the activities on the territory of a given municipality, local municipalities' support is dependent on the personal relations between county governor and municipality leaders. Their influence in the process is also rather strong, mainly through political channels.

Actors and positions

Description of actors and their positions
Ministry of Social Affairssehr unterstützendsehr unterstützend stark dagegen
Other ministriessehr unterstützendunterstützend stark dagegen
County governmentssehr unterstützendunterstützend stark dagegen
Local governmentssehr unterstützendneutral stark dagegen

Influences in policy making and legislation

There was no legal action foreseen for the initiative. However, during consultations while preparing the strategy, it was raised that if the sttrategy and the new principle of regional governance is successful, the concept should form the basis in future public health legislation.

Legislative outcome


Actors and influence

Description of actors and their influence

Ministry of Social Affairssehr großsehr groß kein
Other ministriessehr großgroß kein
County governmentssehr großgroß kein
Local governmentssehr großgroß kein
Ministry of Social AffairsOther ministries, County governmentsLocal governments

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Please see section stakeholder positions.

Monitoring and evaluation

An annual scorecard has been prepared. Each actor and beneficiary shall provide information about implementation and costs to one of the main donor agencies (Ministry of Social Affairs, National Institute for Health Dvevelopment or Estonian Health Insurance Fund) every three months.

The Strategy Council, established with the decree of the Minister of Social Affairs, is responsible for overseeing the implementation. In 2005 most of the activities have been carried out as planned, outcome analysis is planned for 2007 based on a large national Health Survey in autumn 2006. The expected outcomes are:

  • higher population satisfaction with public health services
  • better allocative efficiency of public health care system resources
  • healthier population

Review mechanisms


Dimensions of evaluation

Struktur, Prozess

Expected outcome

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht System gerechter System gerechter
Kosteneffizienz sehr gering high sehr hoch

The policy is very important: alternative solutions to raise the efficiency of public health activities at the local/regional level are needed because revision/formulation of a new Public Health Act is being impeded. The quality of public health services should raise, but most importantly a basic level of services should become available to all citizens and not just the ones living in big and/or richer municipalities.


Sources of Information

National Strategy for Prevention of Cardiovascular Diseases 2005-2020.

Health promotion by Estonian Health Insurance Fund  since 1995 (In Estonian)

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo. "Decentralisation of health promotion programs". Health Policy Monitor, December 2006. Available at