5. Provision of services
he public health system in Lithuania consists of 10 public health centres, subordinated to the Ministry of Health, and a number of specialized agencies with specific functions (radiation protection, emergency situations, health education and disease prevention, communicable disease control, mental health, health surveillance, and public health research and training). At the local level, municipal public health bureaus carry out public health monitoring, health promotion and disease prevention.
Primary care is delivered by a GP or a primary care team. The development of the GP gatekeeping function has been an important goal of the primary health-care reforms. The municipalities administer the entire network of primary health-care institutions through one of two models. In the centralized model, one primary health-care centre manages a pyramid of smaller institutions. In the decentralized model, GP practices or primary care teams are legal entities holding contracts with the NHIF.
Specialist outpatient care in Lithuania is delivered through outpatient departments of hospitals or polyclinics as separate legal entities, as well as through private providers. Specialties with most outpatient attendances are ophthalmology, neurology, ENT, orthopaedics and cardiology.
A major service restructuring has been occurring in specialist services since 2003. Day care, day surgery and outpatient rehabilitation services were significantly developed; specialized hospital units were closed in many local hospitals and services were transferred to multiprofile hospitals. Some institutions were merged.
Emergency care is commonly provided by GPs during services hours. Alternatively, and during the GP out-of-hours times, it is provided by emergency departments of hospitals.
The number of pharmacies increased from 465 in 1993 to 1498 in 2011, and the vast majority of them are privately owned. The number of authorized medicines has also increased to 4659 registered pharmaceuticals in 2010. The level of reimbursement for pharmaceuticals in Lithuania remains low, and access to innovative medicines was shown to be lacking.
In response to the poor mental health of the population, the government adopted national mental health-related programmes and upgraded the infrastructure. In 2012, there were 4 specialized mental health-care hospitals, 5 addiction centres and 20 departments within general hospitals delivering both inpatient and outpatient mental health-care services. In addition, since 1998 a network of local mental health-care centres has been developed.
5.1 Public health
The principal guidelines for the public health service have been outlined in the Health System Law (1994), Lithuanian Health Programme (1998–2010) and the National Public Health Strategy (2006–2013). In 2002, the parliament adopted the Public Health Law and the Public Health Monitoring Law. Other relevant legal documents regulating public health service activities include the Law on Consumer Protection (1994), the Law on Prevention and Prophylaxis of Communicable Diseases (1996), the Law on Alcohol Control (1995), the Law on Tobacco Control (1995), the Law on Product Safety (1999), the Law on Food (2000), the Law on Dangerous Substances Control (2001) and the Occupational Health and Safety Law (2003).
The Public Health Surveillance Service was established within the Ministry of Health in 1994 to replace the Soviet-era sanitary-epidemiological service. In 2000, the SPHS was established under the supervision of the Ministry of Health. It was abolished in 2012 and its functions transferred to a network of 10 regional public health centres and the Ministry of Health. The role of public health centres ranges from health protection to public health strengthening, including public health safety, dealing with health emergencies, consumer rights protection, environmental safety, and prevention and control of communicable diseases. Vilnius Public Health Centre is also responsible for the safety of cosmetic products, food supplements, mineral water and biocides.
In addition, a number of specialized public health agencies have also been reformed or restructured. For example, the Communicable Disease Prophylactics and Control Centre has been merged with the Lithuanian AIDS Centre, and the Lithuanian Health Information Centre has been incorporated into the Hygiene Institute.
Currently, the following public health institutions are under the supervision of the Ministry of Health:
- the Radiation Protection Centre, which is responsible for supervision, assurance and coordination of radiation protection services;
- the Health Emergency Situations Centre, which coordinates preparedness and participates in health emergency management; it is also a WHO collaborating centre on International Health Regulations;
- the Health Education and Disease Prevention Centre, which provides technical support and carries out prevention activities for noncommunicable diseases and injuries as well as education of health professionals and the general public;
- the Centre for Communicable Diseases and AIDS, which implements national policy in prevention and management of communicable diseases; organizes and implements epidemiological surveillance of communicable diseases; organizes and coordinates population-based immunization services; and works in the field of informal education;
- the State Mental Health Centre, which engages in implementation of mental health policy and public mental health measures, including coordination of primary mental health care and monitoring and strengthening population mental health;
- the National Public Health Surveillance Laboratory, which was established in 2003 to test air in housing and workplaces, sewage, sanitary and drinking water, food and non-food products, cosmetics and personal hygiene products, materials and products in direct contact with food, biocides, detergents and chemical products for households; it also performs clinical, diagnostic and environmental laboratory tests, as well as testing of electromagnetic radiation, noise and vibration; and
- the Hygiene Institute, which provides research and training in public health and is made up of the Public Health Technology Centre, the Occupational Health Centre and the Health Information Centre; the last handles health statistics and epidemiology, including state registers of deaths and causes of death, of occupational diseases, and of blood donors.
At the local level, municipal public health bureaus are responsible for a number of functions, including health promotion and disease prevention, population health monitoring, and planning and implementing local public health programmes. The bureaus also collaborate with NGOs, communities, families, other sectors and stakeholders. Currently, there are 33 public health bureaus serving 57 municipalities out of 60 (Kavaliunas, Sceponavicius & Asokliene, 2012). The majority of employees in public health bureaus are public health professionals working with schools; consequently, bureaus have focused on community and child health.
Public health bureaus are set a broad mission, with goals and priorities to promote public health and well-being at the local level. They aim at strengthening the public health planning role of local government by including evidence, community consultation and evaluation. Therefore, development of the bureaus has provided a mean by which local governments, in partnership with the service providers, other stakeholders and the community within the municipality, can plan and implement public health services and programmes (Kalediene et al., 2011).
At the primary health-care level, some public health functions, such as health promotion, primary prevention and immunization, are carried out by GPs. They, along with other medical specialists and dentists, implement national screening programmes financed by the NHIF. Women aged 25–60 years are offered cervical cancer screening every three years, and those aged 50–69 years are offered breast cancer screening every two years. Men aged 50–75 years (and over 45 for those at risk) are eligible for prostate cancer checks every two years. In addition, biannual colorectal cancer screening is available for adults aged 50–75 years; annual screening for those with high cardiovascular risk is available to men aged 40–55 years and women aged 50–65 years, and a dental programme that provides for teeth coating is offered to children aged 6–14 years. These programmes are opportunistic rather than population based. Recently, the NHIF cited evidence that describes most of these programmes as efficient (Momkuviene, 2011).
An integral part of public health policy implementation is carried out through international programmes and projects. Substantial funding has been obtained for strengthening public health system capacities in compliance with EU regulations. In 2013, there are about 50 ongoing projects in public health, financed from the EU structural funds or other international mechanisms (EU Health Programme, WHO, International Atomic Energy Agency), including the development of health impact assessment, professional training, communicable disease prevention, monitoring injuries, reducing health inequalities, strengthening preparedness for emergencies, improving radiation protection, expanding public health laboratory functions and improving mental health.
The main problems in public health services include bureaucratic and financial constraints, lack of intersectoral cooperation, staffing problems and qualifications of the personnel responsible for implementing public health functions. The establishment, funding and activities of local public health depend greatly on political will. Furthermore, the implementation of the Lithuanian Health Programme at the local level is not well defined and often fails to incorporate the effect of short-term strategies on the intermediate and long-term goals of the Programme and the Lithuanian National Public Health Strategy. The quality of public health services and activities is also an urgent issue. However, the development of methodology to assess allocation needs for concrete measures in public health care in municipalities is among governmental priorities (Kalediene et al., 2011).