Estonia in the World Health Organization

In order to explain the foundations, goals and methods of Estonia’s activity in the World Health Organization (WHO), some broader key questions about international health diplomacy need to be addressed. Posing broader and perhaps more philosophical questions needs, first and foremost, to provide an answer to why an international approach to health issues is necessary and where health stands in the broader context of international relations. Based on this understanding, we can answer the question why it is necessary for Estonia to be involved in this organisation and how this can be done in the most useful and efficient way for the country.

What is Health Diplomacy?

In order to explain health diplomacy and its international implementation, we need to start at the very beginning. The WHO was established as a specialised agency of the United Nations at the 1946 International Health Conference on the basis of Article 57 of the Charter of the United Nations. This means that it was created to deal with one specific field, in this case healthcare. The preamble to the WHO constitution clearly outlines the goals and activities of the organisation.
The very first sentence of the constitution states that an important part of the organisation’s activity is aimed at the security of all people. Estonian readers are probably well aware of the extensive national defence model, discussion of which has been wide-ranging and thorough, and so it does not require further explanation. However, I believe that so-called “soft” security threats, including health matters, might require slightly greater attention in the vital services subsection in the non-military sections of the National Defence Development Plan, which should address more than just preparations for a smooth transition to wartime needs.¹ The importance of health in today’s world is also demonstrated by the G7 Leaders’ Declaration “Think Ahead. Act Together” adopted at their summit in Germany on 7–8 June 2015.²
The WHO constitution outlines the elements considered to make up the aforementioned security. The idea is that health is a human right; it is fundamental to the attainment of peace and security; the contribution of each state regarding health is of value to all states; the unequal level of development in countries is one of the main threats (to security); healthy development of a child is of primary importance; an informed public and its active involvement are important in the improvement of the health of the people. This is a selection of the issues that explain the wider concept. We can see that, in addition to security, health diplomacy in a broader sense includes social and economic aspects. When we look at the topic more broadly, healthcare is indeed a topic that relates to a person even before he/she is born and still matters after they die. But is there any other topic that relates to us for longer than we are alive?

A Selection of WHO Topics Important for Estonia

The best way to present an overview of Estonia’s activity in the WHO is to base it on a human lifespan.
HIV/AIDS—A Matter of Existence
There is one healthcare issue that can affect human beings before they are born: HIV/AIDS. It is estimated that, without effective intervention, the virus passes on to 15–45% of infants during pregnancy, birth and breastfeeding, thereby having a pre-natal effect on children.³
Estonia is at the top of several HIV/AIDS-related rankings. Over the years, 9,127 people in Estonia have been diagnosed with the HI virus, including 443 who have been diagnosed with AIDS. As of the end of May 2015, 134 new HIV-positives had been diagnosed in Estonia this year. Compared to the trends of previous years, I dare to assume that, by the end of this year, the number of people newly infected in 2015 will be slightly more positive than the 291 last year. In terms of numbers, the success is not significant but, if we examine long-term trends, we can see important shifts. 2001 was the peak year, with 1,474 new carriers of the virus, and today the number has fallen below 300—an 80% decrease. The majority of this decrease has been among men. There has been a clear shift in the age groups of infected people. In 2008, more than half the newly infected were in the age group 20–29, but since 2010 the trend has shown less than a third of the newly infected are in that age group today. The number of newly infected in the younger age groups has dropped to sixth place: 20–24-year-olds outnumber the next segment, 45–49-year-olds, by 50%. This trend shows that people’s awareness of ways to avoid HIV/AIDS has increased significantly; in addition, various programmes aiming to stop the spread of the virus have been implemented effectively, including syringe exchange and methadone maintenance treatment. The topic has also been covered thoroughly in schools. Taking into account that many of those infected in Estonia are in the fertile age group, the number of cases where the virus is transmitted from mother to child is also rather positive.⁴
The UN programme UNAIDS deals with the fight against HIV/AIDS. Estonia has not been very active in this, mainly because so far it has been a “receiving” country that needs to focus on its own national problem. However, changes in trends, which are proof of successful action, have received positive international feedback. Due to their similar backgrounds, Ukraine—which has the second-largest number of infected people in Eastern Europe—and Central Asian countries are interested in Estonia’s experience. The positive trends give Estonia an opportunity to become a contributing country in HIV/AIDS matters and attempt to join the governing bodies of the international organisation.
Why am I focusing so much on an already much-discussed topic? Estonia was once compared to a country that has the same colours on its national flag: Botswana. The percentages there are far different from Estonia’s—in this African country of 2.1 million people, there are an estimated 300,000 HIV-positives, which is about a quarter of people aged 15 and over. Only Swaziland has more.⁵ In Botswana, life expectancy fell from 64 years to 49 between 1990 and 2002 due to HIV/AIDS. As a result of successful action, life expectancy in Botswana went back up to 53 years by 2012. However, these development trends demonstrate that HIV/AIDS was an epidemic that threatened not only the security of a population but also its very existence.
A Healthy Mind in a Healthy Body
Moving forward along the lifespan, we come to the health of mothers and children. The promotion of breastfeeding is very important for Estonia. This year marks 25 years since the adoption of the Innocenti Declaration, produced in cooperation between the WHO and UNICEF, which places breastfeeding infants at the centre of their healthy growth and development.⁶ The first week of August each year is dedicated to the promotion of breastfeeding. This issue is familiar to Estonians and the country’s breast-milk bank is an asset that could be an example for many developed countries.
From breast milk we can move on to the closely related topic of nutrition—primarily mothers’ nutrition, because there is an obvious link between a healthy mother and a healthy child. Estonians have a relatively varied diet and are far in the lead of developing countries in this respect. However, Estonians also need to be reminded of the principles of a balanced diet. The activity of the National Institute for Health Development, such as last autumn’s campaign “A Man Must Be Fruitful”, may be light-hearted but it also has the necessary substance (and addresses women as well as men) to remind people of the recommendation to eat at least five portions of fruit and vegetables every day.⁷ Programmes promoting balanced school meals serve the same purpose.
This is an important issue, bearing in mind that nutrition is a problem not only for developing countries but also for developed nations—only the narrower focus of the topic differs. An increasing problem for the developed world is the population’s growing bodyweight and insufficient physical activity, which in combination lead to more serious health issues. Research among Estonians indicates that this issue needs to be tackled because the trends are heading in the wrong direction.⁸ The promotion of healthy eating is a clear priority, and Estonia also stands for these principles at the global level.
From nutrition to an increasingly serious issue: antimicrobial resistance (AMR). The resistance of microorganisms to antimicrobial drugs is a growing global trend. At the beginning of June, Estonians learned that quails eggs imported from Latvia—considered to be a great source of vitamins and which, unlike cod-liver oil, are also a children’s favourite—contained traces of antibiotics. AMR is also a problem in agriculture, so providing healthy food requires effective cooperation between different sectors.
The food Estonians currently eat is relatively bio and organic. However, in order to establish a monitoring system for AMR that simultaneously covers veterinary medicine, agriculture and human health, we need to work at the national and international level. Although the problem in Estonia is relatively small, in several southern and Eastern European countries AMR has made the treatment of pneumonia very difficult.
Antibiotics are related to another important topic for Estonia: e-health. An electronic prescription and purchasing medication with the prescribed active agent is nothing virtual but, rather, a clear attempt to avoid the misuse of medication and the unwelcome consequences this causes. It also reveals efforts to improve the provision and accessibility of healthcare services. As tends to happen with systems in the works, in many instances there is room for improvement, but, even compared to many developed countries, the overall system in Estonia today is quite good. The best possible access to healthcare services is a goal for Estonia in the WHO, as well as in the country’s development cooperation and contributions to crisis relief.
Healthcare Support Systems—The Healthcare Provider
Healthcare services do not reach people only via the virtual environment—personnel are also required. The 2010 World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel.⁹ One of the principles of this code is the recognition that there are not enough healthcare personnel in the world and that they move around the globe according to demand and pay. It also integrates aspects of migration—currently a very hot topic, also from the viewpoint of the country’s sustainability and security. The code calls on countries to follow voluntary principles which take into account the capabilities and needs of source countries and destination countries, and the rights, obligations and expectations of migrant healthcare professionals. Estonia is mainly affected by the regional movement of healthcare personnel—many people on a waiting list for medical treatment have probably thought about bringing home Estonian doctors who have moved to Nordic countries. As countries often have different interests on this topic, progress is not being made with Estonia’s otherwise efficient and successful Nordic cooperation. But trends in the cross-border movement of healthcare personnel are under scrutiny across the region.
It is crucial to have an efficient healthcare system and ensure its capacity, as was demonstrated by the Ebola outbreak, which continues to this day. Notwithstanding the Millennium Development Goals, a majority of which are healthcare-related, the creation of sufficiently robust healthcare systems has failed in many countries. The Sustainable Development Goals and targets which will be adopted in New York in September will take the required actions forward. Estonia’s position among the world’s healthcare systems is demonstrated by its being one of the very few countries that have contributed to stopping the Ebola outbreak in three ways: financially, with experienced personnel, and through work by researchers at the University of Tartu on developing an Ebola vaccine. It might be said that this is a small country’s flexibility in rapid-reaction situations, but it is certainly evidence of Estonia’s ability to contribute to global healthcare during a very critical period.
Ebola is also an example of how the relativity of healthcare exceeds the timeframe of human life. Those who have followed the topic know that one of the three goals set by the WHO to end the Ebola outbreak emphasised the importance of safe burial. One way that the extremely contagious disease is transmitted is related to the cultural and religious traditions of the affected region, including interment. There have been several cases in which the deceased person who had been buried in a safe manner by rescue teams was later re-buried in the traditional way, and the disease was transmitted from the deceased after their death. Close cooperation between healthcare workers and cultural anthropologists is essential if such cases are to be avoided.
For countries to be able to contribute effectively to global healthcare, the WHO itself needs to be effective. The expert group on WHO reform, composed of member states, was created at the beginning of this year and includes a representative from Estonia as one of two from the Europe region. One of the aims of the working group is to provide solutions to how the global organisation could act more effectively on three levels of responsibility—global, regional and national.
The results of the reform will certainly affect the (currently) few Estonians who work in the WHO system. In order for Estonia to be more successful in this field, it should attempt to create special courses on healthcare diplomacy in the country’s universities. Compared to, for example, studies on the European Union, the number of specific courses in Estonia about other international organisations is low. Estonia’s presidency of the EU in 2018 provides an opportunity to get much more involved in these topics.
Estonia’s Pride and Joy in the WHO—The Tallinn Charter
Finally, Estonia’s very own creation in the WHO—the Tallinn Charter. This was adopted in 2008 in Tallinn at the WHO European Ministerial Conference on Health Systems, which was titled “Health Systems, Health and Wealth”. The purpose of the charter is to commit member states of the WHO in the Europe region to improving people’s health by strengthening health systems, while acknowledging social, cultural and economic diversity across the region.¹⁰ The preamble to the Charter outlines several issues mentioned in this article: healthcare systems are related to policies in other spheres, to global health challenges, including demographic and epidemiological changes, to limited resources, to the development of technology, and to people’s growing expectations of healthcare services. We know that a healthy body has a healthy mind. Similarly, we can acknowledge that health is an asset in its own right—the improvement of health contributes to the growth of social well-being, affects economic development, competitiveness, and productivity, and helps to establish the wealth of the whole population. In the Tallinn Charter, member states committed to promote shared values but also to invest in health systems and to foster investment across sectors that influence health and, at the same time, to be accountable for health system performance and measurement.

Conclusion

It is clear that the Tallinn Charter is related to all the previously discussed topics with which Estonia is dealing in the WHO. Although the UN and its agencies are often considered prime examples of the inefficiency of global politics, we must admit that healthcare is a sphere that involves everyone—and not only during their lifetime, but also before birth and after death. It is certainly possible to see similarities with the principles of the Estonian constitution. Like international politics and multilateral relations, political processes are two-dimensional. This means that, on one hand, countries contribute on an international level to advance world development while, on the other, the international agenda is also delivered to our doorstep. A strong country demands strong international involvement in those fields as well, whether this means passive observation or active leadership. Taking into account its size and capacity, Estonia’s activity in the WHO can be considered a high-level contribution.
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¹ Summary of “Riigikaitse arengukava 2013–2022 mittesõjalised osad” avalik kokkuvõte
(“Summary of National Defence Development Plan 2013–2022: non-military sections”). http://www.kaitseministeerium.ee/riigikaitse2022/laiapohjaline-riigikaitse/index.html
² https://www.g7germany.de/Content/DE/_Anlagen/G8_G20/2015-06-08-g7-abschluss-eng.pdf?__blob=publicationFile&v=5
³ http://www.avert.org/prevention-mother-child-transmission-pmtct-hiv.htm
⁴ Data are available on the Estonian Health Board website: http://www.terviseamet.ee/nakkushaigused/nakkushaigustesse-haigestumine/hiv-ja-aids.html
⁵ http://www.avert.org/hiv-aids-botswana.htm
⁶ http://www.unicef.org/programme/breastfeeding/innocenti.htm
⁷ http://tervis.postimees.ee/2920491/algas-kampaania-mees-peab-olema-viljakas ⁸ Triin Eglit’s doctoral thesis “Obesity, impaired glucose regulation, metabolic syndrome and their associations with high-molecular-weight adiponectin levels”, defended at the University of Tartu in 2014, offers a good overview of the topic and the situation in Estonia.
⁹ http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_8-en.pdf
¹⁰ http://rahvatervis.ut.ee/bitstream/1/2083/1/WHO2008.pdf

This article was published in ICDS Diplomaatia magazine.