Funding Health Innovation in Estonia: Reflections from the Opinion Festival 2026

The Opinion Festival has been held in Paide every August since 2013. It is open, free, outdoors, and deliberately unglamorous: no badges, no pitch stages, no sponsors’ keynotes. People sit on hay bales and argue in public. It is one of the few settings in Estonia where a regulator, a payer, an investor and a founder will say what they actually think, on the record, without a communications team rewriting it first.

In the Future of Health area, Health Founders Estonia convened a panel on the least glamorous question in health technology: how do you fund a health innovation so that it actually reaches the people who need it?

We went in expecting a conversation about money being scarce. That is not the conversation we got.

The panel was moderated by Mart Toots (Metrosert), panellists were Eva Paalma (Estonian Health Insurance Fund), Kitty Kubo (Ministry of Social Affairs), Helen Maidre (EstBAN, angel investor and founder), and Andreas Kotsjuba (co-founder and CEO of Salu, an online clinic operating in Estonia, Finland and Spain).

The discussion moved through three blocks: adoption of new solutions in the healthcare system, early-stage funding, and Estonia as a test environment.

Mart set the frame at the start. Estonian science in medicine, life sciences and biotechnology is genuinely world-class and has been for a long time. The gap is not discovery. It is what happens between a good result and a patient.

What the panel was actually saying

Four things came through.

1. Nobody in the room defended the status quo

The most striking moment was not a criticism from the private sector. It was the payer describing her own institution.

“We understand that we are a bottleneck – and justifiably so, because we are dealing with public money collected to pay for health services, which is by nature very heavily regulated.” Eva Paalma

That single sentence changes the shape of the debate. If the payer is not defending the constraint as optimal, then the conversation is no longer founders versus the state. It becomes a design problem that nobody currently owns end to end, where each party can see their own segment clearly and nobody can see the whole path.

The same honesty ran in the other direction. Eva also pointed out that the sector’s favourite framing — funding is fragmented, there isn’t enough of it — doesn’t fully survive contact with the evidence. The Health Insurance Fund’s innovation support budget this year is €1.5 million. It funds impact studies: the health-economic evidence that a solution improves outcomes and costs less than what it replaces — the evidence a reimbursement decision later rests on, most often inclusion in the national list of health services, though not every company is aiming for that route. This year it received four idea forms. Last year, nine forms. When the payer came back with clarifying questions, all but one applicant continued the process. 

“Our goal is not to keep that one point five million sitting on the table.” Eva Paalma

The Fund is now analysing its own process to find out where the obstacle sits.

2. The problem has two halves: the gap and the uncertainty

The founders and investors on the panel were not asking for a bigger pot. They were asking to see the shape of the path.

Andreas put it as an opportunity-cost problem: if you cannot tell how long a support mechanism takes, what it requires of you and what the pay-off is, you cannot price it — and the rational decision is to go and build something else with those months. Helen described the trap from the investor’s chair:

“People like me invest a little at the beginning. But it is not enough to reach the market. And it is not enough to get to the next round, because you have not got far enough, not in a highly regulated market like health.” Helen Maidre

Fragmentation is uncomfortable. Unpredictability is disqualifying. Those are different problems and they have different solutions.

3. Estonia has working mechanisms — they are just under-described

Two examples came up that deserve far more attention than they get.

Cardiac telerehabilitation is already reimbursed as a whole service — the price covers device rental, the software licence and the clinician’s time. The payer does not name the digital product that must be used. It sets the conditions the service has to meet, and the provider chooses the solution.

The family physician digital portal arrived at the same principle from the other end: pilots first, then functional and non-functional requirements plus a primary-care funding model derived from what actually worked — and then the market opens to anything that meets the bar.

“Any solution that wants to come to market can come, if it meets the requirements.” Kitty Kubo

Requirements create a market. Buying a single product does not. For anyone building in Estonian healthcare, this is the most practically useful thing that was said all afternoon, and it is barely known outside the rooms where it was decided.

4. The most concrete idea came from another regulated sector entirely

Andreas spent seven years in fintech before founding Salu, and he brought the one proposal that was specific enough to act on.

Becoming a bank normally takes two to three years and around €10 million in capital. Several countries created a limited banking licence instead — smaller requirements, less capital, the right to operate within a defined ceiling. Lithuania adopted this in 2016–2017 and became the home of European fintech.

“It was not a sandbox. It was actual financial companies offering banking products to real customers, within reasonable constraints.” Andreas Kotsjuba

Companies proved in a bounded environment that their thing worked, and many later became full banks. Just as importantly, the regulator learned what digital innovation actually is by supervising it rather than by assessing it on paper.

He offered it as a thought rather than a worked-out proposal: something similar could be built for AI tools in healthcare — controlled and bounded, with real tests rather than theoretical assessment.

Kitty offered the German comparison, where low-risk digital health solutions receive automatic provisional reimbursement for twelve months while evidence is gathered, with the price negotiated afterwards. Belgium and France have adopted versions of it. Its known weakness — manufacturers setting their own first-year price — is exactly the kind of detail worth learning from rather than copying as it stands.

The exchange that stayed with us

Late in the discussion, Kitty made the case that neither the Ministry of Social Affairs nor the Health Insurance Fund is the right place to move earlier in the innovation cycle — into the stage before evidence exists — and start sharing risk with technology companies. Helen pushed back from the investor’s side of the table, in one line: “So you only step in once it’s already a problem and the person is already sick.” Kitty’s reply was that prevention is in their portfolio too. They may not have been answering quite the same question, but the exchange landed on the right place: the stage where evidence still has to be built, and where the risk is highest, has no clear owner.

That is the sentence our expert group now has to answer in writing.

Eva closed the panel on a note we keep coming back to. The value of the afternoon was that these four were at one table at all. People building companies were telling the payer how it could play its role better, and the exchange ran in both directions.

What happens next

This panel was part of the preparation for Health Founders Estonia’s white paper on healthtech funding and adoption in Estonia — a working document from our funding models expert group, describing how the funding path actually runs, where the decision points sit, and who owns each of them.

The expert group is working through the core of it now. As the document takes shape, we will be bringing these questions to a wider group of organisations. If this is your work, you will likely hear from us — and if you would rather not wait, get in touch.