Digital government teaching case study

Challenges of leadership, ownership and partnership: digital vaccine registration in Estonia

Aaron Maniam, Vibhuti Gour, Sarah McAra
Blavatnik School of Government, 2025

Introduction – The Core Dilemmas

In May 2021 ,Siim Sikkut, the Chief Information Officer (CIO) of the Government of Estonia, returned to his office troubled after a meeting with a group of senior officials from the Ministry of Social Affairs. Sikkut had serious concerns about the digital readiness of the ministry’s national COVID-19 healthcare response. In the coming days, the ministry intended to expand vaccination registration for all Estonians over 16 years old – 500,000 people – using the national digital patient portal, Digilugu.[1] Sikkut knew that the portal, built for everyday healthcare needs, could not handle the sudden influx of users and was all but certain to crash, threatening to delay vaccinations, disrupt regular healthcare services, and damage Estonia’s reputation for effective digital government that his office had worked hard to build.

As CIO, Sikkut was responsible for the country’s digital governance, including setting national digital policies and strategy. Estonia was well-known around the world for its efficient and reliable e-services. During the pandemic, Sikkut’s office had been instrumental in ensuring that Estonians continued to have access to public services online. However, Sikkut’s office did not have sole ownership over digital governance. Instead, a hybrid model provided ministries with a high degree of autonomy to drive their own information technology (IT) agendas.[2] IT capabilities were embedded across policy domains, rather than housed centrally. Thus, the lines of responsibility were somewhat blurred: while Sikkut’s office had some ownership over the digital response, final decision-making authority on digital initiatives ultimately lay with each ministry. Despite these nuances in ownership, though, in the public eye, Sikkut’s office was responsible for all of digital government.

Since January, Estonia’s COVID-19 vaccination efforts had proceeded with several delays and distribution challenges. The ministry had initially required health providers to call individuals in their areas who were eligible for vaccines – at-risk groups, healthcare and welfare workers, and later the elderly – to book appointments.[3] This had significantly increased the burden on the already overworked health centres, and many family doctors urged the ministry to move to an online registration system.[4] In March, the ministry finally piloted online vaccination appointments for those over 65 using the Digilugu portal, but it was unable to handle the large number of users who logged in, and it crashed.[5] Users waited in long digital queues, and many received confirmations for appointments that did not exist.[6]

Now, in May, vaccine registrations would open for those over 40, followed soon after for all adults. The ministry continued to see Digilugu as the best option for delivering on a tight deadline and for a complex health system.[7] However, Sikkut was acutely aware that the portal lacked the capacity to handle the additional demands, and believed a crash could be avoided using other technical solutions. He had tried to raise his concerns with the Ministry of Social Affairs and had proposed alternative solutions, including working with a group of private-sector firms which had offered to quickly build a new portal for free. But the ministry, though aware of the issues, had been focused on other health crises. As the government’s digital services seemed headed towards another crash, Sikkut knew he had to act fast, but was uncertain of how to respond.

Background - Digital Governance in Estonia

Since regaining independence from the Union of Soviet Socialist Republics (USSR) in 1991, Estonia has invested massively in internet connectivity throughout the country.[8] The country transitioned from a Soviet-era command economy to a dynamic market-oriented one, and quickly established a reputation for openness, competitiveness, and transparency to attract international investment, particularly from Scandinavia.[9] Prioritising greater integration with the West, Estonia joined the European Union (EU) and the North Atlantic Treaty Organization (NATO) in 2004.[10] It soon became known as one of the most liberal economies in Europe. Key drivers of its economic growth included a robust IT sector, favourable business environment, and strong commitment to digital innovation. The government drove initiatives to encourage start-ups, such as the e-Residency programme, which made it easy for anyone in the world to run a company remotely. The capital, Tallinn, became a popular hub for tech start-ups, including Skype, Bolt, and Wise.[11]

The impetus to digitalise came from the restrictions and opportunities posed by the need to deliver services to the country’s small population (1.3 million people) spread out over a relatively large landmass.[12] At the time of independence, the country had inherited outdated Soviet infrastructure – half the country did not have phone lines – and the internet offered a relatively inexpensive way to govern the large space with little manpower.[13] Further, Estonia’s assigned specialty in the USSR had been computer science.[14] As a result, the country had already developed a talent pool with advanced training in IT.[15]

In the mid-1990s, Estonia became one of the first countries in the world to create an e-government strategy.[16] The strategy paper, prepared by the Estonian IT community, aimed to create a groundwork of principles to establish up-to-date, well-developed state information systems. The central government established a dedicated IT department and created a category for all IT expenditures of the various government agencies in the national budget.[17] As a result, government IT procurement was accounted for collectively. At the time, Estonia lacked the financial resources needed for global consultants, and so the government built much of its technological capacity and skills in-house.[18] According to the former Estonian President Kersti Kaljulaid, “Estonia was a relatively poor country. Our public sector, our government and our civil servants wanted to offer our people good quality services. We did it straight away digitally because it was simply cheaper, easy.”[19]

Estonian citizens had access to a wide range of digital services before such technologies were adopted in many other developed nations. By 2000, Estonians could file their taxes electronically through the e-tax system. The programme was refined over the years to allow tax returns to be completed within three minutes, and was used by 98% of Estonians.[20] In 2005, Estonia was the first country to hold nationwide elections with online voting from any location.[21] By 2007, the portal e-Business, linked to a data registry of all Estonian legal entities, allowed new businesses and non-profits to register themselves online.[22]

These services were highly integrated: citizens could choose to grant public services and businesses access to specific data in their digital portfolio and create links to external databases. For instance, they could authorise tax authorities to retrieve personal data from other government sources and their banks, automatically filling in parts of their income tax declarations.[23] This integration was possible thanks to a few key systems that formed the e-government’s backbone. First, X-Road was a secure data exchange platform that allowed different organisations to communicate, work together and share important information.[24] Second, Estonia’s digital identity system provided citizens with a secure, single identity running across government services.[25] And third, the state e-services portal, called eesti.ee, along with other service portals, formed the government’s service layer.[26] With their digital ID, citizens could access almost all public services online, many of which were connected through X-Road.

As of 2021, Estonia was among Europe’s frontrunners for digital services, according to the Digital Economy and Society Index (DESI), which monitors Europe's overall digital performance.[27]

Siim Sikkut

Sikkut grew up at a time when the government was taking steps to connect schools to the internet and introduce computer science programmes.[28] He gained an “appreciation and fascination for technology” and found himself “hooked in terms of what this great worldwide web was all about.”[29] Sikkut travelled abroad for his higher education, and in 2005, graduated from Princeton University with a bachelor’s in public and international affairs. He later completed a master’s in international management from the University of London.

He spent his early career in strategic planning roles for economic development in the Ministry of Finance, but quickly recognised that Estonia’s chance at having a significant global impact lay in the digital realm.[30] Shifting his professional focus towards e-government, from 2012 to 2017 he worked in the Government Office of Estonia as a digital policy advisor, coordinating the planning and implementation of digital policy across the government.[31]

In 2017, Sikkut became the country’s CIO. He was the second-ever person to hold the position. The first CIO, Sikkut’s predecessor Taavi Kotka, was considered one of the main drivers behind Estonia’s digital success, leaving Sikkut with a substantial legacy to uphold.[32]

Management Structure of Digital Governance

In the 2000s, Estonia’s digital government had a highly decentralised model: major ministries had a high level of responsibility and ownership over their digital programmes.[33] The operating principle was that domain specialisation was important in the design of appropriate IT services, and ministries were best placed to drive their own digitalisation.[34] Decentralisation was also considered important to making the system less vulnerable to failure: a range of interconnected databases was more resilient than one with a single owner.[35]

In the 2010s, the government moved towards a hybrid approach.[36] In 2013, the CIO office was created as a central unit to set national standards and ensure that digital services across different domains were interoperable. Meanwhile, individual government agencies and ministries continued to lead their own digital agendas and build their own systems.[37] (See Exhibit 1 for the organisation of IT services.)

Exhibit 1 Organisation of Estonia’s IT support services as of 2019

Source: Translated from National Audit Office, #e-riik Riigikontrolöri kokkuvõte e-riigiga seotud tähelepanekutest, 11 November 2019, p. 12, available at https://www.riigikontroll.ee/Riigikontrol%c3%b6r/K%c3%b5nedjaesinemised/tabid/163/647GetPage/1/647Year/-1/ItemId/1182/amid/647/language/et-EE/Default.aspx.

The Chief Information Officer

At the central level, the main unit responsible for the development and implementation of IT strategies was the Office of the CIO. The CIO, also named the deputy secretary-general for digital development, sat within the Ministry of Economic Affairs and Communication (MKM), but had a mandate which covered the whole of government.[38] The CIO shaped the country's digital government and policy landscape, set its strategies, and drove key initiatives and regulations related to digital government, national cybersecurity, and connectivity.[39] The team ensured that existing services were updated and running smoothly while also steering the country’s next cycle of digital innovation.

As CIO, Sikkut mainly focused on communicating and coordinating with the rest of the government and steering the overall digital agenda. According to Sikkut, ‘The wording of our mandate was pretty vague, and primarily framed around coordination, so we had a lot of freedom and space in the role.”[40] He had a team of 30 staff.[41] Others on his team, such as the Chief Technology Officer (CTO) Kristo Vaher, looked at the operational side of decentralised digital government, with a focus on ensuring that digital systems in different domains were interoperable and, if required, could easily be reused.[42]

Funding approval was an important lever for the CIO. Funding for e-government came from both EU structural funds and the state budget. According to the National Audit Office, in 2018, Estonia spent €123 million on IT, with €45 million for administration, €38 million for wages, and €40 million for investment.[43] (At the time, this was around 1.3% of the state budget.[44])

From 2014 to 2020 period, Estonia received €163 million from the EU for IT projects. (The Estonian government co-financed 15%, contributing €29 million.[45]) Notably, these structural funds were for new developments, and typically could not be used for maintenance costs.[46]

The CIO office had decision-making power over funding from the EU’s structural funds. For projects funded by the Estonian government, the CIO Office had only an advisory role with the finance ministry.[47] According to Sikkut, “Our only real enforcement tool was money. That was an important lever for everything: new projects, upgrades, and even just keeping the lights on. This meant that some initiatives were driven from the top down. But fundamentally, governance was still decentralised. Ministries led projects. If a ministry did not want to do something, the government CIO could not force it.”[48]

Decentralised IT Centres

Ministries were responsible for the design, implementation, and maintenance of their digital projects.[49] According to Vaher, this decentralisation was intentional so that ministries could have in-house IT experts who could customise digital services.[50] He said, ‘A lot of organisations are making the mistake of centralising IT, which makes no sense, because you want to make sure your engineers are familiar with the specificities of their domain. Something as simple as how to record an individual’s name may mean something different to a doctor as compared to the police. Our strategy was to decentralise IT and ensure that domains are stronger.’[51]

Most large ministries had specialised IT development centres that oversaw their digital projects. Sikkut explained that his team provided “direction and coordination mechanisms so that everybody’s on the same page,” but “every agency is a digital agency in their domain. They’re the service owners and run the show in their field. We try to nudge everybody forward.”[52]

Sikkut observed that the level of digital expertise varied by ministry, meaning that the quality of digital services also varied. He was also aware that few ministers prioritised digital; they often only realised the extent to which their ministry relied on digital tools when something broke.[53]

Private-Sector Collaboration

The digital government was characterised by highly porous networks between government agencies and Estonian IT firms, while the tech sector had many small, interpersonal networks.[54] Public sector officers often called tech-sector executives for advice, both formally and informally. Digital projects were often outsourced, though public officers had a relatively high degree of technological literacy, which allowed them to be closely involved with the design and implementation of projects. The government tended to prefer Estonian firms as vendors as they were often more cost-effective and helped avoid language barriers. The digital landscape of Estonia was also characterised by a relatively high degree of fluidity between public and private sector jobs.[55] Senior government officials driving major digitalisation efforts often came from the private sector, and vice versa.[56] Formal and informal forms of networking encouraged knowledge-sharing and exchange of best practices. For instance, a regular social gathering called ‘Oktoberfest’ created a forum for IT and cyber specialists and engineers to meet informally and exchange ideas on technology.[57]

The Ministry of Social Affairs

The Ministry of Social Affairs was established in 1993 by merging the Ministries of Health, Social Welfare, and Labour. Since 2014, it has been governed by two ministers: the Minister of Social Protection and the Minister of Health and Labour.[58] The secretary general, a civil servant, led the ministry’s administration, while its technical work was carried out under the leadership of four to five deputy secretaries-general for health, social and labour policy, and innovation.[59]

The ministry had much to be proud of. For instance, before COVID-19, Estonian life expectancy had increased by more than any other EU country in the past two decades. The country’s welfare programmes, such as pensions and parental benefits, were also considered generous.[60] However, the ministry was seen as a laggard in digitalisation compared to other sectors. Veiko Lember, a senior researcher at Tallinn University of Technology, and his colleagues, described welfare services and health as having had a “slow rather than rapid change in technological routines,” and noted that technology had a limited impact on administrative capacities.[61]

For some years, the Ministry of Social Affairs lacked the kind of dedicated IT centre that was common in other major ministries. (The three major IT centres, SMIT at the interior ministry, RMIT at the finance ministry, and RIK at the department of law and justice, had been formed between 2010 and 2012.) It was only in 2017 that the Ministry of Social Affairs established the health and welfare information systems centre (TEHIK) to lead the IT services for itself and its agencies.

The aim was to streamline operations and consolidate the data management and analysis of health, social, and labour policies.[62] TEHIK merged the functions of the Estonian e-Health Foundation (active from 2005 to 2016), IT units within the ministry, and information systems of certain agencies such as the Health Board.[63] “TEHIK was a step in the right direction,” said Kalle Killar, who became Deputy Secretary General of e-Services and Innovation at the Ministry of Social Affairs in 2018. “But it was created out of a combination of different IT services, and if you combine weak services together, it doesn’t make it strong. So, I came in when the institution was weak, and my main task was to make it strong and financially sustainable.”[64]

SKAIS II

Just a few years prior, the Ministry of Social Affairs’s lack of digital expertise became apparent with a major project that was widely regarded as a failure.[65] The project, called SKAIS II, sought to upgrade the national social protection information system (SKAIS), which carried out the calculations and payments of all national pensions and benefits. SKAIS II was meant to improve upon an already working system to include more functions and a client-friendly front-end.[66]

SKAIS II was announced by the ministry’s Social Insurance Board in 2013, but quickly ran into multiple challenges. Starting from the procurement phase, timelines for bids were unusually tight: vendors had a little over a month to submit bids that were expected to map a four-year project.[67] In a very short period, the project was awarded to a joint bid made by two Estonian firms, Tieto and Icefire, for €7.1 million scheduled to be completed in 2017.[68] However, by 2015, the project had encountered financial challenges, and the economic affairs ministry had to approve an additional €3.5 million for the project to continue.[69] By December, one of the developers, Icefire, exited the project, and several senior executives from the company publicly acknowledged the project’s poor prospects.[70] Work slowed as Tieto continued alone.

In early 2016, the SKAIS II’s supervisory council, which included then-CIO Kotka, expressed concerns about the project’s feasibility, but the ministry decided to continue. The government entered into fresh agreements with Tieto and applied for funds from the EU and other sources to finance the project.[71] The project’s deadline was pushed by another two years.[72] In 2017, the Ministry of Social Affairs launched TEHIK, which took over the management of the project despite being new. However, SKAIS II still had little to show in terms of results. By June 2017, Tieto had failed to fulfil its contractual obligations and faced a penalty of €0.93 million from the government.[73] Despite spending nearly €6 million on new contracts to other developers for the existing SKAIS system, only 10 out of 42 contracted projects had been completed.[74] In August 2017, the social insurance board decided to end the project.[75]

In the aftermath, there were different analyses of what had gone wrong. According to Tieto’s CEO, Anneli Heinsoo, ‘The social insurance board did not know what they wanted. We were expecting them to contribute and brainstorm with us, but it didn’t happen. They were also short on specialists… We had a client that didn’t know what it needed.”[76] According to Vaher, SKAIS II sought to accomplish too many complex tasks in a single project. “The SKAIS project planned to build a very monolithic system, and this was causing problems. It had no microservices that helped to divide up the project. Nothing that decentralised it internally.”[77]

Sikkut, who became CIO at the very end of SKAIS II, used the opportunity to reform the review process for digital projects. “SKAIS’s failure gave us a footing to strengthen governance,” he noted.[78] For instance, Sikkut’s team, led by Vaher, put in place architectural review boards, which included panels of tech experts from different domains who would do rigorous reviews of digital projects and flag potential risks.[79] According to Sikkut, “We used SKAIS’s example to push through the value of making sure each project goes through the review led by the government CTO.”[80]

The Estonian Health System

Among the Ministry of Social Affairs’ responsibilities was healthcare and its policy development, strategic planning, regulation, and oversight. Within the ministry, the departments of Health System Development, Public Health, and Medicines were led by the deputy secretary general for health.[81] Since 2015, the deputy secretary general for innovation had supported the development of digital services, including e-health services and health registries.[82]

Three subordinate health agencies operated under the ministry’s health division. First, the Health Board implemented and enforced aspects of healthcare, prevention and control of communicable diseases, regulation of medical devices, chemical safety, and environmental safety.[83] During COVID-19, its focus shifted to communicable diseases, and some functions were transferred to the Estonian Health Insurance Fund (EHIF), including stockpiling, distributing and delivering vaccines.[84] Second, the National Institute for Health Development (NIHD) conducted public health research, implemented national health strategies, monitored public health, published health statistics, and maintained medical registries.[85] Third, the State Agency of Medicines (SAM) was responsible for the authorisation and quality control of medicines and the regulation of pharmaceutical trade.[86]

The EHIF, an independent public legal body, organised the financing of the healthcare system. The EHIF pooled public funds and contracted health care providers;[87]it covered healthcare costs, pharmaceutical expenses, temporary sick leave, and maternity benefits.

On the digital side, TEHIK managed the Estonian National Health Information System (ENHIS).[88] TEHIK had to meet the needs of a decentralised healthcare system. For most Estonians, the first point of contact with the healthcare system was through an independent general practitioner (GP), typically at one of Estonia’s more than 400 family physician practices.[89] These primary care centres, often privately owned, selected their own IT systems.[90] As of 2018, there were seven different IT systems used across all hospitals and family doctors.[91] Consequently, any alterations to the central IT system required coordination with healthcare providers nationwide to ensure interoperability. TEHIK, among its duties, facilitated information exchange within the health information system between healthcare providers.[92]

Efforts to Digitalise Health

In the early 2000s, the Ministry of Social Affairs turned to e-solutions for healthcare-related services. It developed the e-Health Foundation (TEHIK’s predecessor), to provide high-quality, accessible healthcare services and develop a nationwide electronic health record (EHR) system.[93] In 2008, the national patient portal, Digilugu, was launched.[94] Estonians could access the portal via their national ID card to see their various medical documents, such as information notes, responses to referrals, e-certificates, ambulance cards, prescriptions, data concerning health insurance, time-critical data and information about their family physician.[95] According to Priit Tohver, adviser for e-services and innovation at the Ministry of Social Affairs: “We have a lot to be proud of, even on an international level, like a fully functional e-prescription, smart support for discovering the co-effects of medicine, e-ambulance and a developing e-consultation service.”[96]

Despite initial momentum, however, Estonia’s e-health was considered to be lagging in digitalisation. Digilugu, launched in 2013, had not been updated by 2021, and its design and functionality had become dated. A national audit conducted in 2014 concluded that despite promising plans, e-health objectives had not been achieved: the uptake of many e-solutions such as digital registration or image referencing systems had remained low, and the data in the e-health system could not be used to treat patients, inform national statistics, or keep registries.[97]

According to the National Audit Office, a major cause of this lapse was the Ministry of Social Affairs’s “aimless and random activity” in their strategic management of the development and implementation of e-health.[98] Their report read, “The Ministry of Social Affairs, whose duty it should be to represent the interests of the state, has been more of an onlooker in the management of e-health. When the risks for managing various e-health projects became clear, nothing was done to address them.”[99] Sikkut agreed that digitalisation of healthcare had long been undervalued and underdelivered. “Digital health was in shambles for years,” he said. “In my previous role in 2013-14 with the PM Office, we went top down to ensure there was a digital health strategy in place. People on the technical level tried their best, but their expertise was not considered important in that sector. Health policy officials, as a result, just did not get digital. Classic health policy was considered more important. Digital was strategically undermanaged, with a high turnover.”[100]

COVID-19 in Estonia

The first case of COVID-19 in Estonia was reported on February 27, 2020. Two weeks later, Estonia declared a state of emergency during which the government closed schools, prohibited public gatherings and events, shut down restaurants and non-essential shops, limited the meeting of people in public spaces, and required remote working as much as possible, among other restrictions.[101] After the state of emergency was lifted two months later, Estonia gradually reopened public life, though with many restrictions still in place.[102] Notably, many public organisations had been able to operate throughout with minimal disruption due to the digital structures already in place, including for schooling, the justice system, benefits applications, and prescription requests.[103]

Estonia’s mortality rate in 2020 was the second lowest in the EU after Finland. However, the weekly reported figures rose significantly in the second wave of COVID-19, and by March 2021, there were more than 775 weekly cases per 100,000 residents. Restrictions were reintroduced in specific regions, and were soon extended to the entire country.[104]

Initial Vaccine Roll-out

By December 2020, the Ministry of Social Affairs approved plans to vaccinate people in January.[105] They began by vaccinating small groups, starting with healthcare workers, welfare service providers, individuals at high risk, and later the elderly. Vaccine registrations were initially done entirely offline: local GPs had to call each individual in their area who was eligible for a vaccine and help them book their appointments.[106] The ministry partly put this system in place with the intention of assisting those among the elderly who were uncomfortable with digital tools. However, family doctors reportedly found this analog solution time-consuming and an unwelcome burden during a time when they were already overworked during the pandemic. As two doctors put it simply: “It takes time to call people.”[107] For instance, while some people readily agreed to get vaccinated, others were more sceptical, and wanted information about the vaccine’s side effects.[108]

There were also issues with the procurement and delivery of vaccines. Often, clinics did not receive the number of doses they were initially promised. According to Ruth Kalda, Head of Estonia’s COVID-19 prevalence survey and a doctor at the Järveotsa Family Medicine Center, when they found out they had not received enough vaccines, they would “need to call the people again, apologize and tell them we cannot vaccinate them right away after all.”[109] Some reports indicated that county-level health data was being recorded by hand rather than digitally.[110] Many doctors called for a digital registration system. According to Eero Merilind, family doctor at the Meditiim Family Medicine Center, “We are calling people today, while our hopes lie with a digital system.”[111] Toomas Hendrik Ilves, former president of Estonia, said it was “shameful” that the public could not register for a vaccination online.[112]

In mid-March, the ministry introduced online vaccine registration for people 65 years and older.[113] According to the Health Insurance Fund director, Rain Laane, “…we will use a digital registration option to offer vaccination times, because booking a time slot digitally lessens the burden of healthcare workers, who would otherwise call each person one by one.”[114]

Using the existing Digilugu platform, the team at TEHIK allowed healthcare institutions to publish vaccination slots online. As healthcare providers used separate IT systems, they were required to opt in to the digital registration platform. When registrations first opened for people aged 65 and up, only 22 healthcare providers had joined the platform.[115] On the user side, those seeking appointments had to log in to the portal where, if they were in the target age group for vaccinations, they would receive a notification with the option to book an available location and time slot.[116] People could also directly contact the reception services of individual hospitals or private healthcare institutions that were providing vaccinations. The director of TEHIK, Katrin Reinhold, said that creating a digital method for vaccine registration was important to allow people to find suitable locations and time slots.[117]

The ministry was aware that the Digilugu system had not been designed with a pandemic in mind. Reinhold noted that since there were over 300,000 people in the over-65 age group, it was possible that the digital registration could crash when overloaded, such as during the weekends. (According to the National Audit Office, 293,000 people visited the portal in all of 2018.[118]) Reinhold said, “We are prepared for a significant bump in digital registration visits. In case the system is overloaded due to increased visits and you cannot book right away, it is worth trying again after some time.”[119]

Despite efforts to prepare the public for the site’s limited capacity, the system crashed on the first day of testing.[120] As one newspaper reported, “The digital registration system is throwing up error messages left and right that become traps that snap shut [the system] when one clicks on them.”[121] By midnight, the system sent some people notifications confirming successful registrations. However, these were errors: the Digilugu system had not recorded their bookings.[122] Challenges continued later in May. The ministry opened registrations for those over the age of 50 on May 3, but when users went to book appointments that morning, they could not access the system. A TEHIK spokesperson asked for the public’s patience as they resolved the issue.[123]

The digital government faced considerable media scrutiny with each system failure, with public anger towards Digilugu. According to one reporter, “The need for IT investments has been ignored for years, with every agency left to its own devices. There is no big picture, no one in charge of the whole system. People forced to use the systems we have are in agony.”[124] Sikkut reflected, “If vaccination registration doesn't work, the whole government is considered guilty, especially the government CIO office, because we're supposed to do digital stuff. The public asks, ‘why the **** don’t digital things work?’ And you need to be able to answer them.”[125]

Expanding Vaccine Registration

A few weeks later, the Ministry of Social Affairs announced plans to open vaccine registration slots via the national health portal for those over 40 years beginning on May, 13. In an unexpected move, the ministry also announced that slots would open for those 16 and over just four days later, on May 17.[126] At the time, 500,000 adults in Estonia had yet to be vaccinated.[127]

“Elderly and vulnerable people received the vaccine first,” Killar explained. “However, the demand among these groups was low, and so the government decided to open vaccines for everyone. The decision was made overnight and we [TEHIK] were told afterwards. No one asked for our expertise.”[128] Killar and his team highlighted the risks and the limitations of their IT system in discussions with the working group on vaccines. TEHIK needed more time to build up the required capacity. “We informed the ministry that what they wanted was technically too difficult,” he said. “But the decision was political. It was already done.”[129]

The public also had some doubts. In a radio interview, Prime Minister Kaja Kallas was asked whether she could be sure the system would work on May 17, following its earlier challenges. “[When] the announcement went out for 50-year-olds to register for vaccination, naturally, there was more pressure, and the flaws became apparent,” she said. “These errors are being corrected continuously to ensure that it functions correctly. So, in that sense, it has certainly improved… But, of course, I can't say that we won't encounter any bumps along the way.”[130]

Sikkut’s Dilemma

While Killar’s team had to scramble to accommodate the government’s decision, Sikkut remained concerned about the continued use of the national health portal for registrations. He reflected, “The national health portal had an online doctor’s appointment registration tool. And then, overnight, they [the Ministry of Social Affairs] tried to use that module for vaccine registrations as well. But the portal’s architecture was not ready for that kind of scale. It was built for peacetime.”[131]

Moreover, the national health portal was used for all healthcare services, including those unrelated to COVID-19. Long queues and system crashes would mean that people who needed to access the portal for any health reason, such as accessing prescriptions, booking consultations, or checking test results, would be unable to do so. A crash of the health portal could unnecessarily burden an already strained health service.

As CIO, Sikkut had some responsibility to alert the ministry to his concerns and coordinate with the ministry’s IT teams to devise solutions. However, the ministry remained responsible for its digital projects. Sikkut reflected, “The hard thing about digital is that you are rarely in charge of the whole thing. It’s fundamentally a coordination role. And so, you must ask, “How can we coordinate better?”’[132] Sikkut’s team tried to use various levers to effect change. He explained, “Firstly, we had the minister work at different levels, trying to ideate, getting an understanding of the situation, and trying to lobby with them to change course. Secondly, we had private sector teams ready to work pro bono. They remained a standby reserve capability.”[133] However, Sikkut was aware he could not force a solution upon the ministry, as this could lead to different problems in future, like poor uptake of technology by unwilling staff. [134]

Sikkut proposed one solution to the ministry: he had been approached by a consortium of private-sector firms who offered their talent and skills (pro bono) to build up a new “quick-and-dirty” vaccine registration portal which would accommodate more users without clogging up the health portal for others to use.[135] Sikkut knew the solution was a makeshift one, but given the crisis situation, he considered it to be as good as any other. Sikkut was on good terms with many firms. He knew that they had no long-term commercial interest in the project; they had reached out due to their long-standing relationship with Sikkut and history of collaboration, plus their willingness to give back to the country, especially in times of need. Moreover, other collaborations with the IT sector during COVID-19 had been successful. For instance, family doctors and the EHIF began using an app to improve vaccine distribution, which was developed in just three weeks by a logistics start-up and a team of volunteers.[136]

Killar, however, had a different point of view. He knew that the IT companies were capable of putting in place a high-quality registration system, but saw their proposal as a long-term project. His team believed that attempting to quickly build and switch to a new system overnight would not be cost-effective. Further, Estonia’s digital health system was completely decentralised, especially with each healthcare provider operating their own IT system. As Killar said, “Can you imagine having to integrate these changes between the central system and also all the individual ones? If we put in place an entirely new system which was not integrated with what doctors were using, it would create a lot of confusion. Health centres were already overburdened. To then ask them to switch systems – there was no way we could do this.”[137] He added, “If we were to change the registration of the central portal, we would have to change the separate systems of healthcare providers as well. The entire project would take four to five months if we worked quickly.”[138]

Instead of opting for a private solution, Killar and his team focused on minimising risks and working quickly to bolster the current digital registration system’s capabilities. They had to not only prevent Digilugu from crashing, but also protect the separate IT systems of different healthcare providers.[139] For instance, they discussed changing the internal rules to restrict people to registering in specific counties, so that users would not spend a long time on the portal searching for appointments in different areas.[140] They also discussed creating a limit of 5,000 users who could access the site at any given time, creating a digital queue for the rest.[141] Killar reflected, “Given the time constraints, there was not much we could do. We could not significantly upgrade the system. There were some things in the business logic of Digilugu that we couldn’t change rapidly. The queue system was put in place to ensure the entire system does not collapse.”[142] The head of the COVID-19 vaccination team, Marek Seer, anticipated high interest in the first days. Seer asked the public to be patient; if there were queues, he told them, ‘[p] lease come back later and not give up on vaccination.”[143]

Another System Failure?

Sikkut had a good relationship with Killar, and they had collaborated on many other digital solutions during the pandemic. But Sikkut also knew that ultimately, neither he nor Killar were the decision-makers on the vaccine registration issue. “It was a decision for the health policy side of the ministry. And that’s how it should be. Digital folks shouldn’t steal the show.”[144] Yet Sikkut could not shake off the weight of responsibility that came with the possibility of another system failure, knowing it would further disrupt essential healthcare services and reflect poorly on the entire digital government. With the clock ticking, Sikkut found himself at a crossroads. Should he let the matter be, and simply accept that a failure, which he thought was entirely preventable, was likely imminent? Or could he find ways to continue to push for solutions within the constraints of the decentralised system?

Actions and Reactions (Epilogue)

Note: When this case has been previously taught, this section was released as an Epilogue, after class discussions, so that student responses were not over-anchored on a perceived “correct” or “actual” answer. See the Teaching Note for details.

On the night of Wednesday, May 12, 2021, vaccination registration opened for those over 40 on the Digilugu system.[1] By Thursday morning, the system had crashed, with users causing a jam that affected the entire portal, meaning users could not book consultations with specialists or access COVID-19 test results, among other services.[2] By Monday, May 17, when registration opened for all, there were over 22,000 users in the digital queue waiting to book vaccines, with a waiting time of more than an hour.[3] By one report, on the afternoon of May 18, there were 36,000 people in the digital queue.[4]

Citizens were frustrated. One Estonian explained the experience: “I wanted to go to the digital registry this morning to make an appointment. At first, I couldn't get into the system at all – a message appeared on the screen saying that there was a technical error. When I got in, there were about 10,000 people in line in front of me. I thought I'd check again later, but then there were already about 20,000 people ahead of me. A complete madhouse! When will it end?”[5] A member of the opposition, Jevgeni Ossinovski, stated, “…this is a really bad show, considering that the people at the Ministry of Social Affairs knew in advance that it would happen.”[6] Amidst this frustration, the head of public relations of the health and welfare information systems centre (TEHIK) explained that delays were also partly caused by limited vaccine supplies. She stated, “It is necessary to understand that when the hospitals run out of vacant slots, the TEHIK user help cannot do anything.”[7]

On May 18, Marek Seer, the head of the working group on COVID-19 vaccination, apologised for their design decisions. “It must be admitted that our decision, where the waiting room is located in front of the patient portal, and not in front of the digital registry, has not been successful. At that point in time, it seemed like a good option, looking back now, I would decide otherwise,” he said. ‘“t should also be taken into account that the digital registry is strongly intertwined with the IT systems of healthcare institutions, and therefore there are no quick solutions,” he added. “We apologize to those users who have to wait in a shared queue to use other Patient Portal services.”[8] Gea Otsa, communications advisor to the vaccination working group, also explained that while they knew the system needed greater capacity, the team had decided they could not justify the costs for what would be a short-term surge in use. “This would not be a wise use of taxpayers' money. This is a one-time need,” Otsa said.[9]

“At the end of the day, it was not a heroic story,” CIO Siim Sikkut said. “The ministry didn’t see using the portal as an issue at all. And that’s the ministry’s call. Ultimately, it was not a digital choice.”[10] He added, “But in the public’s eye, it was a digital government failure.”[11] Sikkut later reflected that the challenges with vaccine registration started important conversations on how to improve government-wide digital governance processes. “The experience framed our thinking on how to change governance overall,” he said.[12] For instance, they started to discuss some form of “emergency powers” over IT systems for the CIO team to take over in crisis scenarios. “There’s no way to stop a project of another ministry. There’s no lever for that currently,” Sikkut said. “And I don’t want to advocate for that – we chose to be outsiders.”[13]

Further Reflections

The case highlights several issues that can be taken up in subsequent classes or discussion sessions. These are included here for completeness, but should probably not be released to students with the main case text, so as not to overly shape their views on the case’s key insights while dealing with initial discussions. After the case has been discussed and dissected, however, these issues will be brought into sharper relief:

What might an optimal organisational structure look like, for a successful digital ecosystem – or do all organisational structures have different mixes of pros and cons? The case explores the merits and demerits of a relatively decentralised approach, with digital agencies exercising moral suasion but little executive authority. How might governments design ecosystems in countries with differing developmental and policy circumstances? How might systems ensure the right level and quality of strategy-policy-ops-tech integration (see Teaching Objectives in the Teaching Note), so that policy priorities and trade-offs are set by all relevant players and not just in either a top down way without sufficient technical or operational input, or a bottom up manner without sufficient consideration of strategy and policy considerations? This connects the case with the broader universe of ideas explored in Unit 8 of the TPSDA syllabus.
The necessity of internal government technological skills for successful digital transformation – what are these skills (e.g. technical skills like engineering, programming and coding; leadership and change management skills; skills in procurement and contracting)? How can they be developed, including and especially in digital laggard agencies? For instance, in this case, Sikkut and other individuals throughout the government possessed technical skills, but were dealing with colleagues in a ministry with low digital literacy. Could a more technically literate Ministry of Social Affairs / TEHIK have found ways to make Sikkut’s idea of collaborating with the private sector work, e.g. using API’s to pump only required data into the system, rather than adopt an all-or-nothing approach assuming the need for end-to-end integration of an entire workflow, in the middle of a public health crisis? Students can discuss the trade-offs of three ways of obtaining these skills (e.g,. train internal staff, hire external consultants, secondments and other temporary support). This theme links to TPSDA Unit 2 (Digital Systems) and Unit 3 (Iteration), examining the skills required for informed choices on system component design and when iterative practices can deliver better outcomes than linear waterfall methods.
What is the role of personality and appetite for risk and change among leaders of digital systems? The case illustrates the pros and cons of a relatively risk-averse approach to change, and can be used to prompt students to reflect on both their own risk appetites, and those of leaders they have encountered, when faced with significant decisions relating to digital technology. This point highlights a key aspect underlying all units of the TPSDA syllabus: that public leadership in the digital age presents a unique mix of requirements – some technical, others more attitudinal and mindset-related – about which students will need to be aware and make literate choices.

Conclusion

Note: When this case was previously taught, this segment was discussed and summarized in class, but not released to students as part of the case narrative, so as not to pre-empt their responses during class discussion.

This case helps to illustrate potential barriers officials face in government bureaucracies – even those committed to digitalisation – when trying to deploy digital skills and practices. These barriers include: managing competing priorities in a crisis; time pressures; challenges posed by decentralisation in digital governance; technical hurdles and a lack of digital skills; and the psychology of change. Through the case discussion, students will gain experience in both identifying these barriers and creating solutions to overcome them.

Additionally, the case explores how the relationship between central-coordinating agencies and policy-implementing agencies both impacts and is impacted by the adoption of digital technology in governments. Who has authority over the key decisions in the case, and who has an interest in the decisions but no authority in making them? During the case discussion, students can assess the advantages and drawbacks of different structures of digital governance to better understand how to navigate them. Students can use the opportunity to reflect on what structure (or mix of structures) might work best in jurisdictions of interest to them.

The case highlights that for a digital transformation to work, there must be a foundation of balance between decentralisation and centralisation, receptivity to change, and necessary digital skills before a crisis. Looking at the ecology of the Estonian system, some technical digital skills were present, but they were not consistent (e.g., not in the health and Ministry of Social Affairs). In terms of leadership, there was a government CIO to focus on digital strategy, but with no direct control over ministry decisions. Procurement systems were in place to work with the private sector, but were not consistently used. These factors shaped the options available to Sikkut at the time of the crisis, often in a way that constrained his manoeuvring space.

The case also underscores how, beyond making technical decisions, public officials must learn to articulate digital strategies and priorities so that generalist policymakers, service providers, and the general public can understand key aspects (e.g. the main ways the technology works, the impact on citizen life and citizen experience of using the technology). Effective communication builds trust and supports successful implementation, and cannot be developed quickly in a crisis; these investments need to be made in more stable “peacetime” conditions.