"Changing one's weight is like changing human nature — it's not easy at all. Most people who struggle with it would like to lose weight, but biologically, it's just very difficult," said Vallo Volke, professor of endocrine physiology at the University of Tartu.

According to 2022 data, 33 percent of Estonians aged 16 to 64 were overweight and 21 percent were obese. Previous studies have shown that while lifestyle changes can lead to short-term weight loss, the effects tend to fade quickly.

In recent years, a new and effective option for weight loss has emerged with semaglutide-based medications such as Ozempic and Wegovy. Volke, senior health economics analyst Katrin Koiduaru of the University of Tartu's Center for Health Technology Assessment and their co-authors examined whether using semaglutide would be cost-effective in Estonia. They also evaluated its potential impact on the Health Insurance Fund's budget.

"The main conclusion of the report was that offering semaglutide therapy broadly to everyone would not be reasonable — neither financially nor clinically," Koiduaru said.

Even a cheap option would be too expensive

According to Vallo Volke, semaglutide is the first medication proven to effectively reduce body weight. "Since then, an even more powerful molecule, tirzepatide, has entered the market, but semaglutide was revolutionary up to that point," he said. However, he acknowledged that such medication will not "make an entire population healthy."

The cost-effectiveness calculations by the report's authors support that conclusion. As Katrin Koiduaru explained, cost-effectiveness means that compared with standard practice, the additional cost per added quality-adjusted life year — or incremental cost-effectiveness ratio — remains below the threshold society is willing to pay for one additional quality year of life. "It's important that a patient's life is not only longer but also lived in good quality. If the intervention exceeds that threshold, it's not cost-effective. If it stays below, it is," Koiduaru said.

In Estonia, the conditional threshold for chronic diseases is set at €20,000. "The report shows that semaglutide's incremental cost-effectiveness ratio was slightly above €32,000. So in fact, semaglutide treatment is not cost-effective in Estonia," Koiduaru noted. In other words, recommending semaglutide treatment to all patients would not pay off — financially or clinically.

According to Koiduaru, the drug could become cost-effective if its price were lowered enough to fit within the threshold. Volke, however, pointed out that even if the incremental cost per quality-adjusted life year were €19,999, the treatment would still be unaffordable if the target group included 200,000 people. "The total cost to the system would be so large that Estonia simply couldn't afford even a cost-effective intervention, because the Health Insurance Fund's budget doesn't allow it," he said.

Option for a small group of people

Both authors acknowledge that the report reflects the state of scientific literature as of 2023. For that reason, it does not account for newer findings on the prevention of heart disease. "The report therefore somewhat underestimates the potential benefits this medication can bring," said Vallo Volke.

He added that prices are already trending downward. "In the report, we recommended considering the funding of semaglutide treatment. But the starting point should be the highest-risk group — those with the most severe obesity and the heaviest burden of related diseases," he explained. Katrin Koiduaru agreed, noting that funding semaglutide for everyone would cost hundreds of millions of euros. "If funding could be limited to a smaller target group that would gain the most benefit, it could be reasonable under certain conditions," she said.

Another possible treatment for obesity is bariatric or weight-reduction surgery. According to Volke, this option helps only a small number of people, since patients must first meet specific criteria. In addition, the procedure significantly alters the anatomy of the stomach and intestines. "Fewer than 10 percent of eligible people agree to undergo the surgery. It's a solution for severe obesity, but not for the general population," the professor explained.

When assessing cost-effectiveness, the report's authors compared both semaglutide treatment and bariatric surgery to lifestyle changes. "We evaluated the cost-effectiveness of these interventions within a narrower patient group. In that group, semaglutide's incremental cost-effectiveness ratio was just over €20,000, so staying below the threshold would not be impossible," Koiduaru recalled.

Regardless of treatment type, she said, the societal goal should be to help people live as many years in good health as possible — not merely to extend life, but to extend healthy life. According to Volke, the most effective strategy would still be prevention. "We need to focus on our children — it's that simple. If we teach them to eat well and enjoy physical activity, we can gradually solve this problem across society," he said.

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