Audit: Estonia failing to fulfill its obligations to people with mental disorders

TALLINN - The Estonian Social Insurance Board and the Ministry of Social Affairs do not perform their statutory obligation to ensure special care services to people with mental disorders, the National Audit Office says in its latest audit report.

Although the share of the budget for special care in the operating expenditure of the government sector has remained stable, it has not ensured accessibility as the number of people in need of assistance is increasing. The government and the Riigikogu have been aware of the problems for years but have failed to take decisions that would bring about changes.

In its overview, the National Audit Office looked for an answer to the question of whether the special care services organized by the state are accessible.

"The short answer is no," said Rauno Vinni, the audit manager of the National Audit Office. "There is a severe shortage of service places for people with intellectual disabilities and mental health conditions, and the number of people in the waiting list for special care services has almost doubled between 2018 and 2024. As a result, waiting lists are unreasonably long, with median waiting times ranging from 14 months to 53 months for different services," he added.

The longest waiting lists are for 24-hour services, which are meant for people with a high need for support and to which a person in the regular waiting list may not be able to access in their lifetime if the current situation continues.

Representative organizations of people with disabilities and mental disorders described to the National Audit Office several cases where people have to go through a challenging journey for years to find a suitable place. For example, it was not possible to find a suitable service place for a young adult with an autism spectrum disorder within four years. A number of different service places were tried, but none of them proved suitable. For example, in one case, a service provider did not manage to provide a service to the young person. In another place, however, the level of development of the rest of the people using the service was so different that a more independent and mobile person did not fit in there.

Such complex situations are not uncommon. However, dealing and communicating with authorities is often a challenge for families, which is why even legal aid is involved to receive the service. While the most suitable service is a 24-hour special care service meant for people with an autism spectrum disorder, where the ordinary waiting list shows no hope of finding a place, families are already looking for assistance abroad.

"These are just a few examples of many, but they illustrate vividly how difficult it can be to receive assistance. Accessing a state service should not be so complicated that a person has to hire a lawyer or, if worse comes to worst, look for a service place abroad," Vinni said.

According to the Social Welfare Act, special care -- as well as the rest of social welfare assistance -- must be provided taking first into consideration the person's need for assistance.

"In reality, however, the provision of assistance depends on the availability of money and service places. The Social Insurance Board is in a situation where it is not able to provide a service to all people in need of assistance. However, people’s need for assistance remains and, in the absence of the necessary service, worsens," said Vinni.

Therefore, the National Audit Office finds that in a situation where the state is short of money, the performance of the statutory obligations of the state must be prioritized and assistance must be directed to people with the highest need for assistance in order to minimize possible damage. However, neither the Social Insurance Board nor the Ministry of Social Affairs have found any solutions thereto.

Thereby the delay of the assistance prescribed by law must be explained to people. The National Audit Office asked the Social Insurance Board, which organizes special care, whether they do so.

"The Board replied that they treat all people in the waiting list equally, that is, they do not explain to any of them why there is no money or place for them," the audit manager said.

"This is not a dignified way to treat people. People are waiting for the assistance from the state that has been assigned to them, and they deserve at least an honest explanation as to why they do not receive it within a reasonable period of time," he added.

A particularly important issue in special care is how long a reasonable period of time for receiving assistance is. In 2013, the Tallinn Circuit Court of Appeal, in one of the few disputes on this issue, assessed the reasonable time limit and stated that a sufficient period for the Social Insurance Board to find money after the decision to provide the service is three months. However, people still have to wait for years in the waiting list for special care services.

"We must not become accustomed to the state’s failure to meet its obligations," said Vinni. "Not the authorities themselves, but certainly not people and their close relatives -- it is necessary to be demanding."

The National Audit Office finds that the state cannot leave its obligations to be borne by local authorities and demand more from them than it can do itself. The Ministry of Social Affairs has submitted requests for additional funding for special care over the years, but the additional funding so far has failed to increase the volume or improve the quality of services. However, if the Social Insurance Board has identified a need for assistance, it should be used as a basis for providing assistance and a suitable service place should be ensured within a reasonable period of time. If the state requires local authorities to provide people in need of assistance with immediate social welfare assistance, it should also perform its own obligations at the same time.

According to the National Audit Office, the development of the field requires making services more needs-based and streamlining the waiting list system. The development of services has stalled for years due to the lack of money and interest. But it is not just about the money, in addition to additional resources, the field needs substantive changes, and the future plans of the Ministry of Social Affairs would require more decisiveness

Special care services are assistance organized by the state, which is organized by the Social Insurance Board, which issues activity licenses, processes applications submitted by people and assesses the applicant's need for assistance and support, organizes referrals to services and administers waiting lists. The services are provided by private companies, local authorities and a state company. There are 11 different types of special care services in total, together with the main statutory types and sub-types based on diagnoses and needs. The National Audit Office analyzed ten of them, for which a person has to submit an application.

More generally, special care services can be divided into two groups: support services and 24-hour services. Between 2018 and 2024, the number of people on the waiting lists of special care services for both support and 24-hour services has almost doubled, from 832 to 1,614 people for support services and from 613 to 1,101 people for 24-hour services.

There has been a slight increase in the number of places filled in support services: at the beginning of 2018, the number was 4,445 and, at the beginning of 2024, the same number was 5,132. At the same time, the number of places filled in 24-hour services has decreased from 2,379 to 2,171. One person can receive different services at the same time, such as employment support and community living services, and the number of service places filled does not reflect the number of unique people receiving the service. The National Audit Office found that the number and locations of service places fell short of the demand.