Continuing this week on the under-5 mortality rate (U5MR) demographic twin pairing (recall South Sudan last week) left me with many options. I could explore the Nordic exemplars of Finland or Norway, dive into island-states like the Marshall Islands or Tonga, or examine post-Soviet states like Slovenia, Lithuania, and Estonia. I settled on the latter group, simply because it’s a set of countries where I know relatively little both from a demographic and culinary perspective (priorities!)
Turns out, I hit all 3 of the themes above by focusing on Estonia. It is Nordic-adjacent, it has 2,317 islands within its territorial waters in the Baltic Sea, and re-established independence in 1991 from Soviet occupation. In 2001, it also became the first former Eastern Bloc country to win the Eurovision Song Contest, a topic we will return to in later sections of this post, because how can we not?
Most importantly, for purposes of this topic, it is Estonia’s very low U5MR, at just about 2 deaths per 1,000 live births, that is remarkable. Not only that, the pace of decline is an interesting story, with the country in the top 3 annual declines in U5MR globally between 1990 and 2023. It stands out amongst other similar countries and Europe itself:
Source: UN Inter-agency Group for Child Mortality Estimation
[Yes, the green line is Finland and I was tempted to write about it given the amazing, adorable, effective baby box. However, I think that is a commonly known tradition, so I wanted to see what else was responsible for driving down U5MR in a country that is not known to be in the headlines.]
What are children under 5 dying from in Estonia?
While the rate is low, even 2 deaths (per 1,000 live births) is 2 too many. Using data from IHME’s Global Burden of Disease study, Our World in Data has a nice graphic from 2023. About 38% died from birth disorders (including preterm birth, heart abnormalities, neonatal sepsis etc.); 31% died from non-communicable diseases (cardiovascular diseases, genetic blood disorders etc.); and 12% each from respiratory infections (pneumonia, flu) and injuries (suffocation, falls, animal contact etc.)
I wish I knew this visual existed last week, alas, we are all a work in progress. Here it is for South Sudan.
Source: Our World in Data
One major thing jumped out at me: that both countries have a high % dying from birth disorders. It’s at 25% of all U5 deaths for South Sudan, and 38% for Estonia. So, what gives?
For that, it’s helpful to start even before 1991.
Estonia’s Health System
During the period of Soviet occupation (starting in the 1940s and lasting 50 years), Estonia was integrated into the Semashko health system, dominated by publicly owned medical facilities, salaried health workers, large providers of PHC, and an exceptionally high degree of governmental administration. This system was designed to tackle the challenges of the 2nd and 3rd stages of the epidemiological transition, i.e. those that focused largely on infectious disease control and maternal hygiene. However, Estonia had already overcome these challenges prior to the occupation, so there was a mismatch in what Estonia needed, and the health system that it got. The result was essentially a stagnation in mortality rates (overall, not just U5MR) that lasted from the early 1960s until the end of the 1990s. While other countries in Western Europe saw steady improvements in life expectancy and child survival during this time period, Estonia’s indicators during that time remained flat. Interestingly, the early 1990s period (following the restoration of sovereignty for many countries post-Soviet occupation), saw declines in health indicators as countries (including Estonia) faced the economic shock of a fast transition to a market economy.
Things began to shift with radical reforms in the 1990s. At that time, tuberculosis rates were high, especially from multi-drug resistant tuberculosis (are you thinking about antimicrobial resistance in South Sudan too? Yeah, unexpected parallels!) Concurrently, rates of smoking and alcohol consumption were high: The weekly consumption of alcohol in Estonia was significantly higher among both men and women in Estonia than in the other Baltic countries in the ‘90s. Enter, reforms:
The new government launched several significant reforms soon after regaining independence including the establishment of a national health insurance fund (EHIF) in 1991, financed through a 13 percent wage tax, which now accounts for two-thirds of all health expenditure. Other reforms include decentralizing the responsibility for health service delivery; reducing hospital bed capacity; and initiating reforms to strengthen Primary Health Care (PHC). The reforms were undertaken partly in response to the changing needs of the Estonian population and - given the state of the economy - partly in response to concerns about financial sustainability. Despite the lack of resources, the most significant health system reforms were initiated during the period when Estonia was still a middle-income country.
- Source: Kasekamp K, Habicht T, Kalda R. The Milestones of Reforming Primary Health Care in Estonia. Lancet Global Health Commission on Financing Primary Health Care. Working Paper No. 3. 2022.
I am not a health systems expert, so if you want to read the ins and outs, I recommend this piece. In short: Estonia successfully implemented a new “family medicine” speciality and training, new organizational structures of private practitioners, user choice of family physicians, new payment methods, service contracts for family physicians, broader scope of services and several initiatives to improve quality of care supported by innovative e-health solutions.
The family medicine doctors replaced pediatricians, and were tasked with children’s health in addition to adult health. This worked on many levels, and doctors received payment (capitation) based on the number of patients on their list, incentivizing them to keep their patient population healthy through prevention measures rather than performing unnecessary procedures. The capitation aimed to cover the costs for the salary of a family doctor and a nurse and a defined set of equipment and certain laboratory tests. Additionally, to ensure access in rural areas, a lump sum to cover the expenses of family doctors in rural areas working 20- 40 km and more than 40 km from the nearest specialist care provider was established. The number of activities as part of getting a capitation was (is?) quite comprehensive:
Source: Lancet Global Health Commission on Financing Primary Health Care (2022)
(The new system worked well. Hospital bed capacity reduced dramatically, reflecting a massive shift in resources from acute inpatient care to preventive care. Tying back directly to U5MR, it enabled doctors to catch neonatal sepsis and related illnesses (responsible for 7.6% of deaths) during routine home visits and assessments covered by the capitation package.
To support this utopia, Estonia implemented forward-thinking fiscal and digital reforms. Recognizing the limitations of payroll taxes, the government broadened its revenue base by introducing state budget contributions to cover non-working pensioners, ensuring the system’s long-term financial stability. Complementing this is a sophisticated digital infrastructure which facilitated seamless communication and electronic referrals between primary and secondary care.
Quality of care was a major plot device, with something called the Quality Bonus Scheme (QBS) introduced in 2006. It was meant to further motivate family doctors to widen their scope of services including preventive services, and to manage patients with chronic conditions - to avoid high expenditures, reduce hospitalization and patients’ incapacity to work. It also aimed to reduce morbidity from vaccine-preventable diseases, which are directly linked to child health and outcomes. By 2022, the share of children stunted (a key indicator of chronic malnutrition and poor primary care) was <2%. This is pretty remarkable, because nutrition and health markers in childhood stay the course and show up later in life:
If an individual [in old age] is limited in his or her daily activities, risky health behaviors have probably already contributed to the onset of chronic conditions. The main diseases that account for increased probability of being limited in one’s activities are an accumulation of a set of factors, among which risky health behaviors have played an important part. In the case of Estonia, chronic conditions might also reflect the effects of malnutrition in childhood and various childhood infections, the effect of injuries and life-long nutritional habits, and also the accumulated effect of the past health care system.
- Source: Costa (2005)
e-Everything
Fun fact: Estonia is recognized as a global leader in digital governance, offering 99% of public services online 24/7. From online voting, paperless bureaucracy, digital IDs, the state has built a formidable reputation as one of the most technologically advanced societies in the world. In the 2023 parliamentary elections, more than half of all voters cast their ballots online for the first time. The milestone underlined the depth of public trust in Estonia’s digital infrastructure – something many countries still struggle to build.
Consider this excerpt from an interview with former President, Kersti Kaljulaid:
Tasks like filing tax returns or registering a business take just a few minutes online—there are no queues, and there is no waiting for approvals in person. This convenience fosters trust in government; people see it as practical and reliable. A core part of our success is simplifying processes before digitalising them. Many countries simply digitise archaic or overly complicated procedures, creating a “digitally enhanced bureaucracy” rather than a truly efficient system. In Estonia, we scrutinise the process first and then digitise what remains so that our solutions deliver actual value. I always say that everything rests on the unified digital identity. Estonians authenticate themselves with an ID card, Mobile-ID, or Smart-ID, meaning they don’t need multiple logins or passwords for different services. It’s a guaranteed failure if you don’t unify your identity systems.
-Source: e-Estonia
E-health
Taking a page from the e-everything, is one of the main e-somethings, which is e-health. Almost all Estonian residents have a digital health record, almost all prescriptions are digitized, and an online consultation service facilitates collaboration between GPs and specialist doctors.
Laboratory results are transmitted in real time, eliminating the traditional waiting periods of days or weeks. The system also features nationwide digital prescriptions that are instantly available at any pharmacy across the country – a standard since 2010. Patients retain full control over their data, including visibility into who has accessed their records. Central to it is the X-Road data exchange layer. it ensures secure and seamless communication between healthcare systems, allowing agencies to share data without duplicating it or compromising confidentiality. It is possible for different stakeholders—whether hospitals, pharmacies, or government agencies—to access critical information in real time. Real-time data transmission and digital prescriptions must ensure that infants with acute infections (recall, which account for 12% of deaths via respiratory issues), receive immediate and accurate intervention without a long waiting period common in lower-resource settings.
The Vanemahüvitis system
Maternal health outcomes are equally exceptional, and are directly related to low U5MR. In 2023, the total number of women who died during pregnancy or childbirth was virtually zero. Additionally, all births are attended by skilled health staff, which ensures that events like birth asphyxia are minimized.
Several hospitals have adopted WHO’s 10 steps to successful breastfeeding, which are known to improve child health and outcomes. This clinical environment supports the immediate initiation of breastfeeding, which is proven to lower neonatal mortality risks:
Source: WHO
Perhaps one of the biggest reasons sustained breastfeeding is possible in a country like Estonia is the enabling work environment that supports it.
At workplaces, mothers returning to work before the child turns 1.5 years old are entitled to additional breaks for breastfeeding. These breaks, lasting up to 30 minutes each, can be taken every 3 hours and can also be used for collecting breastmilk. If needed, the breaks can be taken at home or in a suitable location. For mothers feeding 2 or more children up to 1.5 years old, the break duration must be at least 1 hour. Importantly, these breaks are considered part of working hours and are supported by the current social law system, which was extensively updated between 2018 and 2022.
To further promote breastfeeding, the Ministry of Social Affairs established the Estonian Committee for Breastfeeding Promotion, which coordinates awareness-raising efforts. Several hospitals have also joined the Baby-Friendly Hospital Initiative, launched by WHO and the United Nations Children’s Fund (UNICEF) to protect, develop and promote breastfeeding, creating a supportive environment for breastfeeding mothers.
In 2021, 69% of 6-month-old infants, and 33% of 12-month-old infants in Estonia were able to experience the nurturing benefits of partial or exclusive breastfeeding.
-Source: WHO
The Vanemahüvitis (parental benefit) system is powerful. Consider this: Estonia offers mothers the longest duration of leave (in the world!) at full pay at 85 weeks. The flexibility is amazing: It starts 70 days before the expected date of birth. Fathers are entitled to paternity leave as well, lasting for 30 working days. These benefits allow for the intensive, long-term monitoring of infants. This is particularly salient if the baby is born with heart abnormalities or preterm complications, providing the parental and nutritional support that clinical environments alone cannot replicate.
While this level of bonding and care is critical to child health (and thus the low U5MR), it has not actually resulted in increasing fertility rates in the country over sustained periods of time, apart from some promising bumps. You can read more about drivers unique to Estonia here.
If you read my piece on the South Korea TFR, you would be familiar with the policy debates on low fertility and implications for population decline. This is happening in Estonia as well, with one recent headline stating, “Estonia warned it may have just 5 years to reverse population collapse.”
I digress. Overall, a combination of these workplace supports and institutionalizing work-life balance, Estonia ensures that many factors that are responsible for child well-being are optimized.
A petition for more outdoor napping and forest schools
While Kimaya was doing her cutie pie research, she told me a fun fact: Estonia has the cleanest air in Europe! This turned out to be true, and it got me down the rabbit hole of researching about the environment and child health. Well, dear reader - a goldmine!
There is a radical embrace of the natural environment in child-rearing, even in frigid weather. In Estonia (and Nordic countries), it is common to leave infants to nap outdoors in strollers, even when temperatures are low. This tradition is encouraged by midwives and other practitioners as a way to toughen up the child’s immune system and expose them to fresh air.
Source: A mom blog(?) don’t judge.
OK I did not find any large-scale studies that proved (or disproved) immune-boosting effects, but hey, if it ensures babies get that clean crisp air and are exposed to fewer germs in indoor environments, it sounds great to me. See how quickly my evidence-based nature goes when tantalized by this tradition?
Another fun aspect I found is the embrace of Metsalasteaed, or forest schools. As a big proponent of outdoor education (my kids have been in some version of a forest school from age 2-8), this made me so happy:
Scandinavian-style forest schools and nurseries are spreading all around the world. Outdoor learning is increasing seen as an important way of connecting children with nature.
A wealth of studies have shown that spending time in natural spaces has many health and psychological benefits for children, such as reduced obesity, improved mental wellbeing, increased resilience and faster cognitive development. It can also encourage the development of environmentally conscious behaviour by fostering an appreciation and respect for the natural world.
-BBC (2023)
A study on younger children, where parents evaluated their children’s active play, revealed that about 60% of children spend two or more hours per day being active outside of school hours (playing physical games both outdoors and indoors). All in all, by reducing exposure to pathogenic bacteria and viruses in enclosed daycares, Estonia seems to mitigate the risk of pneumonia and the flu, which remain top causes of death under-5. Additionally, this fosters a level of physical literacy and supervised outdoor risk that paradoxically makes children more resilient to the “accidental” injuries that plague indoor, sedentary environments (also a top cause of death we have seen.)
The Lottery of Birth
Today, Estonia’s U5MR is not just much-improved, it is among the lowest in the world, often outperforming much wealthier Western European nations. It serves as a powerful testament that when you marry fiscal sustainability with digital transparency and primary care, the most vulnerable members of society don’t just survive; they thrive. While one cannot change the stagnation of the past, you can certainly code a healthier future for the next generation.
Estonia and South Sudan are worlds apart, but their U5MR data (not the numbers, but %) reveal a shared biological vulnerability. In both countries, birth disorders remain a primary challenge, accounting for 38% of under-5 deaths in Estonia and 25% in South Sudan. The difference, however, lies in what the governments are able to do (and the resources they have) to address the underlying causes. Looking at these countries side-by-side undoubtedly reveals the demographic privilege of birthplace lottery. Whether one is born and lives in the place where the child’s potential is made possible, rather than a miracle performed against all odds.
I leave you with this amazing map that Tess (my friend Kristen’s middle schooler) made. How talented is she?! Those details! The windmills! The next generation is going to be just fine :)
The Food!
We made Frikadellisupp (meatballs in a soup - sounds absurd to eat soggy meatballs but was very fortifying w all the veggies) and Rosolje (beet and potato salad with salted herring), and Hapukapsa-kalasalat (sauerkraut and herring on rye). We delighted in the Estonian Eurovision song playlist, and watched the video of the 2001 winner, “Everybody,” which made everyone laugh and cringe a lot. Kimaya did a whole lot of nature and history research (the national flower is a cornflower), and everyone said they would not mind eating that soup again. Win!
So cool to read this! Especially after having recently met someone who spent quality time in Tallinn and even had a baby there