Primary care in a post-communist country 10 years later: Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004
Introduction
Lithuania's independence in 1990 marked a new era with drastic changes affecting all sectors of society, including health care. The inefficient and poorly maintained Soviet health care system started to be transformed into a social health insurance system with provision based on primary care. Large numbers of physicians were trained for new roles in primary care. This article evaluates changes between 1994 and 2004 in the provision of specific curative and preventive tasks by Lithuanian primary care physicians. Service profiles of GPs in 2004 will be related to the positions they held in 1994 before they were re-trained.
In the centralized Soviet health system physicians were state employees and provision was specialist oriented [1]. First line physicians, both district therapists trained in internal medicine and district pediatricians specialized in child care, worked in the community and were mainly involved in preventive routines and administrative duties, like sickness certification [2]. Curative services were mostly provided by directly accessible medical specialists in policlinics, usually located in cities. Rural health centres (ambulatories), provided a limited set of health services. So the principle of equal access to health care was not materialized [3], [4], [5]. Other imperfections of the system were bureaucracy, lack of efficiency and poor coordination and continuity as a result of strict centralism and a hierarchical approach [6]. This situation worsened due to the abominable state of the Soviet economy, resulting in arrears and outdated facilities [4], [5]. Like Estonia, Lithuania belonged to the early adopters of a pro-primary care policy [7], [8].
Scheme 1 summarizes relevant changes in the health reforms of the 1990s in Lithuania.
The adoption in 1991 by the Lithuanian Parliament of the National Health Care System Conception resulted in the establishment of a statutory health insurance fund (the State Patient Fund) [9]. From 1996 the relationship between financers and providers was set by contracts. Decentralisation resulted in municipalities governing ambulatories, health centres (de-concentrated former policlinics) and part of the hospitals. Patient centeredness and primary care were strengthened by the introduction of specially trained GPs as personal doctors in a gatekeeping position, working either in public or private practice and paid capitation fees [8], [10], [11]. At two new departments of Family Medicine a residency programme was developed [12]. World Bank projects have helped to modernize health facilities and to create new smaller scale centres. As intended, by 2005 almost all previous district therapists and pediatricians were retrained and most of them were working as GPs. With an average of 1600 patients per GP, the country needs about 2200 GPs. This number has almost been achieved and consists for about three quarters of retrained district therapists and pediatricians and one quarter of GPs from the residency programme. Between 1998 and 2004 the total number of primary care centres doubled to 432; 149 of which being private [13].
The study aimed to assess changes in the service profile of primary care physicians between 1994, when then old system was still dominant, and 2004. Policy measures were intended to strengthen the capacity of primary care and to transfer tasks from specialists to GPs. So, GPs were expected to provide more services and have more patient contacts than district therapists and pediatricians did. A higher workload may result in a relative shift from home visits to office contacts. Compared to 1994 more tasks considered in this study would be adopted by GPs in 2004. In particular, a higher involvement of GPs is expected in the provision of medical procedure tasks (such as minor surgery) and disease management. Regarding preventive tasks, it is difficult to formulate clear a priori expectations. The Soviet system used to be strongly focused on collective prevention [1], but in the absence of current incentives for prevention an increase in curative work may just as well be at the expense of preventive services. Based on these goals and expectations the following research questions have been formulated:
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Do GPs in 2004 have more patient contacts than district therapists and district pediatricians in1994?
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Are GPs in 2004 more involved in the provision of specific curative and preventive services than district therapists and district pediatricians in1994?
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Do GPs, who used to be district therapists, still differ in their task profile and in the number of patient contacts, from GPs who used to be district pediatricians?
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Have GPs who graduated from the new residency programme different task profiles and a different number of patient contacts than re-trained physicians?
Section snippets
The questionnaire
The repeated cross-sectional study is based on a questionnaire completed by samples of district therapists and district pediatricians in 1994 and GPs in 2004. In both years the questionnaire contained identical questions on the provision of the following services:
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medical technical procedures;
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management and follow up of diseases;
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preventive services and health education.
Results
In the tables, results have been broken down by the type of physician. In 1994 these were: district therapists and district pediatricians. In 2004 we distinguished three subgroups of GPs: those who used to be district therapists and district pediatricians, respectively and those graduated from the residency programme.
Discussion
Comparison of data from 1994 and 2004 has shown how roles of Lithuanian primary care physicians in the provision of curative and preventive services developed. Moreover, variation in the reported provision of services by GPs in 2004 appeared to be clearly related to the vocational background before being GPs. Quantitative measures show that GPs in 2004 seem to be much busier than primary care physicians 10 years before. Not only do they report to see 60% more patients in their office, the range
Conclusions
Indeed, primary care in Lithuania has become stronger in the past decade and prevention has not been neglected. It seems this change has been facilitated by the introduction of patients listed with a GP and the gate keeping system. However, the full implementation of the chosen primary care based model requires continued efforts [22]. It may be concluded that the Lithuanian health care system is still in the midst of transition. Changing attitudes and established positions takes time, but in
Acknowledgements
The authors acknowledge Birute Zenkeviciute, Harald Abrahamse and colleagues for their contributions to the implementation of the study, data handling and drafts of this paper. The 1994 survey has been funded by the EC in the framework of the Biomed 1 programme. The 2004 survey has been part of a Matra project, funded by the Ministry of Foreign Affairs of the Netherlands.
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