Estonia and Finland – the question of centralisation and decentralisation of digital healthcare

Estonia and Finland are among the leading countries in digital healthcare, although they followed two different approaches regarding eHealth services. Estonia launched its health information system in 2008, becoming the first country in the world to fully implement such a system nationwide. Finland began the development of its national EHR as early as 2002, with the launch in 2007.

Today these countries boast some of the highest eHealth adoption statistics in Europe.


According to our ESPON project eHealth, while healthcare in Estonia, in general, has been almost completely decentralised since the passing of the Health Services Organization Act (2002), the introduction of digital healthcare has been handled centrally. At the present, the services landscape is dominated by the solutions developed centrally by the state and relying on the national health information system

eHealth forms a part of a broader framework of public e-services under the concept of e-Estonia, which, in addition to eHealth, includes other services like e-taxes, e-school, e-commercial registries, and e-elections. The Government CIO Office at the Ministry of Economic Affairs and Communications (MoEAC) is at the top of the e-Estonia horizontal governance. It is in charge of shaping the broad information society policy framework, taking care of the central infrastructure (X-road and ID card) and technology standards, and co-ordinating ICT and e-services development across the public sector.

The Estonian approach translates that by 2018 100% of billing in healthcare and prescriptions, 97% of hospital discharge letters, 60% of ambulatory case summaries, 60% of dental care summaries and 50% referrals are digital. 1.6 million people have documents in the health information system and 34 million different documents are stored here: 21 million summaries of visits or treatments and discharge letters; 1.7 million referrals; 7.5 million diagnostic study reports and procedures. Every month doctors make 1.9 million queries in the health information system and there are 244,369 unique visitors to the patient portal (15% of the population).


For the Finnish healthcare system, eHealth project found that it is highly decentralised, comprised of a three-level publicly funded healthcare system as well as a considerably smaller private sector. Regional outreach and impact are achieved by the means of regional level planning and prioritisation, which is ultimately carried out via the allocation of project funding and further monetary means. Regional or local authorities are ultimately responsible for the provision of healthcare to their respective residents. Within this system, the National Electronic Health Record KanTa collects data from various healthcare providers.

By 2018 digitalisation has reached a level of coverage of 100% for Finnish healthcare systems, where its counterpart dealing with social affairs is expected to soon follow suit. A 100% use of electronic patient records by primary health centres and secondary care hospital districts, as well as 100% coverage of EHR in the public, and 80% coverage of EHR in the private sector all help to illustrate Finland’s achievements.

Cross-border digital healthcare

Nordic countries stand out among EU Member States due to their willingness to engage in cross-border cooperation for digital healthcare. Examples of Nordic cooperation include the Nordic eHealth Research Centre (NeRN) of the Nordic Council of Ministers, that was established in 2012. The NeRN’s core aspiration is to establish a governance system for the collection of data and formulation and monitoring of eHealth strategies, thereby manifesting a currently absent coherent policy document for the Nordics.

The potential scope of this collaboration, however, expands beyond the geographic scope of the Nordics, as demonstrated by the gradually intensified collaboration with the WHO over the past years in several projects, such as the prospective, but not yet completed, development of an eHealth maturity index.  In addition, the internationally operating database “NOWBASE” within the Nordics stands out as one of the most noteworthy recent advancements.

NOWBASE is a shared interface for the Nordic Medico-Statistical Committee (NOMESCO) and the Nordic Social Statistical Committee (NOSOSCO), who collaboratively seek to ensure that health and social statistics in the Nordic countries are comparable across borders, gathering statistics in associated fields is feasible and facilitated, and presenting, processing and managing gathered data is promoted and encouraged.

However, while the Nordic countries have enjoyed similar legal systems which would result in achieving cohesion faster, Finnish and Estonian legal systems are notable for their difference, Estonia having a more permissive approach to legislation and a centralised approach towards digitisation while Finland is characterised by its decentralised digital healthcare.

Despite the differences in legal systems, Finland and Estonia have signed an agreement for joint cross-border cooperation to allow healthcare providers access to healthcare databases. This allows access to digital prescriptions and to full patient medical history. The opportunity to use ePrescriptions abroad benefits citizens by making the management of medications treatment easier, while pharmacies benefit from the improved data quality for their activities because digital prescriptions issued in another country becomes available in a standardized form and in the local language. The mutual commitment is represented by the launch of the Nordic Institute of Interoperability Standards (NIIS) in Tallinn.

Find more on our ESPON project eHealth page