Improving financial protection and access: Managing co-payments for outpatient prescription medicines through digital technologies in Estonia.

Introduction: Estonian households faced persistent financial hardship due to high out-of-pocket payments for outpatient prescription medicines. An "additional medicine benefit" was therefore introduced in 2003, which lowers co-payments once a person's spending for outpatient prescription medicine has reached a threshold. However uptake remained low due to administrative hurdles and lack of awareness. In response, Estonia reformed this benefit in 2018, including leveraging digital technologies to automate eligibility checks and benefit provision at the point of sale. This paper explores how Estonia developed, designed and implemented these digital technologies and analyses the reform's observed changes. Methods: This study employed a qualitative-dominant mixed-methods approach, including document reviews, key informant interviews, and analysis of administrative data from the Estonian Health Insurance Fund (EHIF). The WHO framework for assessing digital technologies in health financing guided data collection and thematic analysis. Results: Built on Estonia's e-prescription system, the reform included lowering co-payment thresholds coupled with automating a member's benefit and enabling related real-time data exchange. The share of patients benefitting rose from 0.4% in 2017 to 15.6% in 2018, which is assumed to have contributed to decreasing the incidence of catastrophic health spending during the same time. Automation has significantly reduced the administrative burdens for EHIF, pharmacists and patients. Conclusion: Estonia's experience demonstrates how digital technologies support health financing reforms, contributing to increased efficiency, improved financial protection and utilization aligned with need. Yet, there is further potential to use existing data and digital technologies to better target benefits to those most in need.