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Lithuania is one of those previous Semashko system countries which until the 1990th had a centralised, highly regulated and hospital oriented health care system. Since restitution of independence, as most of East European countries, Lithuania has started a reform aiming to introduce stronger, based on family medicine, primary health care1 . Postgraduate training of Family Physicians through 3 years residency, has started in 1992. District physicians (internists and paediatricians), whose role was the most close to that of PHC physician, were retrained to family physicians2 .
In 2010 there were 40.7 physicians and 5.7 general practitioners per 10 000 inhabitants, 6,5 visits to physicians in general and 2,8 visits to primary health care physicians per one inhabitant per year. The number of family physicians has notably increased in recent years: from 2.77 in 2001 to 5.7 in 2010 per 10 000 inhabitants3 .
At the end of 2009 primary health care was provided by 1951 family doctors (68 % out of all primary health care physicians), 479 district internists (17%) and 447 (15%) district paediatricians. To guarantee wider range of medical services district internists and paediatricians are working in teams with 342 gynaecologists and 218 surgeons4 .
After the reform the number of PHC institutions has markedly changed: the amount of PHC centres increased by 2.4 times and the private sector increased by 34 times. Implementation of the health care system with private independent contractors was started in 1999, when an EU funded project for the support of the PHC reform process enabled family doctors to establish private practices. Recently half of primary health care institutions are private and they have listed 27 percent of the total population in the country. Various organisational forms of PHC institutions are present in Lithuania:
Despite strong intentions to separate primary and secondary health care in late 1990th, in two bigger cities the policlinic model still exist.
Currently the PHC system is financed from a compulsory health insurance fund and depends on the number of registered patients to PHC institution, patient’s age, performance indicators and provision of preventive health care programs. The predominant payment model in Lithuania is capitation fee (seven age groups) which account for about 80 to 85% of all payment models. The remaining part of payment models is composed of incentive payments (fee for service) and bonus payments for good results. Fee for service payment is for screening of prostate and cervical cancer, care of pregnant women, preventive check-up of children, nursing at home of chronically ill patients, etc. There are bonus payments for results: diagnostics of early stages of cancer (since 2003) and since 2008 more bonuses for quality of care of chronically ill patients5 . The main preventive programs performed in primary care are: cervical cancer preventive program (women 25 till 60 years), breast cancer preventive program (women 50 till 69 years), prostate cancer early diagnostics program (men 50-75 years old), occult blood testing for intestine cancer (men and women 50-74 years), and cardiovascular preventive program (for men 40-55 years, women 50-65 years)2. However, most of family physicians in Lithuania are poorly involved and not paid for out-of-hours primary care. The family physician also has a gatekeeper’s role which was introduced in 1997 and the accessibility to specialists has been limited4. Simultaneously the workload of family physicians increased and has now become one of the most debated issues. Also there are unequal quality and comprehensiveness of services, comparing different PHC providers. Despite the gatekeeping function, differences in referral rates within different health care units are up to five time higher which cannot be explained by the morbidity level of the population6 .
Future priorities for development of Lithuanian PHC were defined in the Outline for the Development of Lithuanian Health Care System in 2011 – 2020, accepted by the Lithuanian Parliament in 2011. More attention in the future should be given to the introduction of more advanced incentive payment schemes to increase focus on preventive activities, for better consideration of community health needs by monitoring morbidity and mortality rates, for the improvement of comprehensiveness of services provided by family doctors and nurses, for spreading private independent contractors and for creation of more equal funding and competition conditions for private and public PHC providers. Following data from Vilnius Teritiorial Sickness fund in 2002, population listed to private independent PHC contractors consumed less than twice of overall health care resources compared to public polyclinics. Since 2006 decreased regulation of the private PHC providers and spread of mixed private practices, mini-polyclinics which provide primary health care (mainly capitation fee) and out-patient specialised services (paid fee for service) act as an obstacle for high quality PHC development. They have higher referral rates compared to specialised services6. At the moment lots of discussions have been initiated by the new social democratic government that wants contracts with private PHC practices to be stopped, or at least substantially revised and priority for health care should be given to governmental institutions. So the future of different organisational forms of primary health care and regulation of services remains unclear.