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Public health development in the Baltic countries (1992–2005): from problems to policy

Julia S. O’Connor, Vaida Bankauskaite
DOI: http://dx.doi.org/10.1093/eurpub/ckn097 586-592 First published online: 23 October 2008

Abstract

Background: The focus of the article is on organizational reform measures in public health in Estonia, Latvia and Lithuania from 1992 to 2005 and the associated changes in population health. Methods: The study draws on published reports and analyses official statistics over time and cross-nationally. Changes in population health are measured by indicators of population health status and indicators of primary prevention or avoidable mortality, which reflect performance of national health policy. Results: Our study shows some similarities and some important differences in terms of public health development in the Baltic countries since beginning of the 1990s. Conclusions: This study highlights the importance of political stability and support in achieving public health improvements and the pervasive influence of socio-demographic factors on several key health indicators in Baltic countries. It points to the need to introduce evidence-based public health interventions, enhance social trust, address corruption and tackle poverty.

  • public health
  • Estonia
  • Latvia
  • Lithuania
  • reform
  • convergence

Introduction

This article describes the development of public health in Estonia, Latvia and Lithuania from 1992 to 2005. These three Baltic countries regained their political independence in the beginning of the 1990s and joined the EU in 2004. Like other countries in transition, each has experienced major political, economic and social changes and significant changes in the structure and organization of their health systems over the past decade and a half but it cannot be assumed that the impact of similar pressures and influences have identical outcomes, in particular public health outcomes. In the context of the absence of systematic comparative analysis of public health development in Baltic countries, the focus of this article is on organizational and policy reform measures and their impact on population health as measured by selected key outcome indicators and their change over time.

Methods

The study draws on previously published reports and analyses official statistics over time and cross-nationally. The results of reforms are measured by population health indicators: life expectancy and neonatal deaths, mortality rates (circulatory system diseases, malignant neoplasm, external causes, suicides and selected alcohol-related causes) and morbidity [incidence of tuberculosis (TB), HIV infections]. In addition, indicators of primary prevention (as reflected in avoidable mortality indicators such as cirrhosis of liver, motor vehicle accidents and malignant neoplasm of trachea, bronchus and lungs) are presented.

In addition to the analysis of change or its absence in public health indicators in each of the countries over time we explore the evidence for convergence, divergence or parallel development across the three countries in these measures from 1992 to 2005. Convergence is indicated if the difference between the countries is less in 2005 than in 1992, divergence is indicated if the difference in the later period is greater. Parallel development refers to the same level of difference at both times. A decrease in the variation across the entire groups of units, here countries, on a particular dimension (sigma convergence) is measured by the standard deviation or the coefficient of variation—the latter is used here because it takes into account the difference in the means at the two time points. A necessary condition for this overall convergence is catch-up by some units (β convergence), but the opposite is not necessary; we could find catch-up by some units without a decrease in the variation measured across the entire group. These distinctions are important for interpretation of results.1,2 In discussing catch-up we focus on the EU15 as the benchmark against which catch-up is measured.

Results

Organizational structure of public health

In the beginning of the 1990s, the Baltic countries inherited the centralized Soviet sanitary-epidemiological system. This system was responsible for delivering immunization programmes, controlling infectious diseases outbreaks, collecting epidemiological data, monitoring and regulating sanitation and hygiene and was organized around local sanitary-epidemiological stations. The focus was on infectious diseases and hygiene while evidence-based interventions were not common. Physicians working in the sanitary-epidemiology system underwent a programme on ‘hygiene’ during their undergraduate training in the medical universities. Since the 1990s physicians working in this system, now known as specialists in public health, undergo a postgraduate training programme in all Baltic countries.

Post-Soviet era reform patterns had some similarities and some differences across the three countries. Starting from the base provided by the Soviet sanitary-epidemiological system each initially adopted a radical decentralization approach in the early 1990s and later modified this in the direction of greater centralization of financing but to a considerably lesser extent than that which characterized their pre-1990s systems.2 A three level administrative system, national, county/district and municipal, was established in each of the countries (table 1). At the national level, all the three countries have the Ministry of Health and specialized public health agencies. In Latvia, the Public Health Agency was created in 2001 with the key objectives of ensuring implementation of public health policy and carrying out research on public health. Other specialized agencies include the Health Statistics and Medical Technology State Agency, State Addiction Agency, Health Promotion State Agency. In Lithuania, the State Public Health Service (under the auspice of the Ministry of Health) was established in 2000. Specialized public health agencies include the Center for Emergency Situations, the Health Information Centre and the Institute of Hygiene. The National Public Health Research Centre created in 2003 is responsible for executing various tests, such as microbiology and environmental health tests (e.g. noise, electromagnetic fields, indoor air quality) and does not deal with health policy or management. In Estonia, the National Institute for Health Development, established in 2003 through the merger of three smaller government institutions, aims to be a national centre of excellence in public health, with responsibility for applied research and analysis in public health (including policy, management and financing), public health monitoring and reporting, coordination of national public health programmes.3

View this table:
Table 1

Responsibilities for public health issues at different administrative levels

Level of governmentEstoniaLatviaLithuania
NationalMinistry of Social Affairs and the National Institute for Health Development, established in 2003, are responsible for public health policy.Ministry of Health and Public Health Agency (established in 2001) are responsible for the national public health strategy. Examples of other specialized agencies in public health are Health Statistics and Medical Technology State Agency, State Addiction Agency, Health Promotion State Agency.Ministry of Health and the State Public Health Services (established in 2001) are responsible for the overall strategy of public health. There are over 10 specialized agencies in public health at the national level.
County/districtCounty Health Councils implement public health intervention programmes. County Health Protection Inspectorate and Labour Inspectorate take part in public health implementation. Since 2001, the county doctors do not have any responsibilities in public health.Ten regional environmental health centres deal with public health at district level. They are responsible for ensuring access to and provision of health care, and establishing and maintaining medical institutions, health and educational institutions and homes for orphan children.County doctors are responsible for public health in their counties.
MunicipalSince 2001, municipal governments have no legal responsibility for funding or organizing health care, but continue to play a role in hospital governance.Municipalities are responsible of ensuring access to health services, promoting healthy lifestyles, restricting alcoholism and ensuring public safety. Local governments reimburse health care expenses incurred by low income people, and they exempt low income patients from patient fees.Municipal public health office is responsible of the public health issues of the municipality. Municipal doctor is responsible for implementing public health programmes. Municipal health boards carry out advisory function.

Below the national level, Estonia and Lithuania (but not Latvia) created the county and municipal doctors’ positions in the 1990s to strengthen the role of local levels in implementation of public health policy; however, since 2002 county doctors do not have public health responsibilities in Estonia. County-level institutions (county doctors, the county office of the Health Protection Inspectorate and the county office of the Labour Inspectorate) still represent separate vertical systems in Estonia and there is insufficient information exchange, planning or cooperation amongst them.3 In Lithuania, the appointment of municipal and county doctors was accompanied by the creation of municipal public health boards to ensure public participation in health policy. Ten regional environmental health centres at the district level in Latvia are accountable to the National Environmental Health Centre and mainly deal with hygiene and control functions while 10 regional branches of the Latvian Public Health Agency are accountable to this agency. Latvian municipalities’ responsibilities include assuring access to health care, promoting healthy lifestyles, restricting alcoholism and ensuring public safety.4

Change in health status from 1992 to 2005

At the beginning of the 1990s, the Baltic countries shared similar public health problems, such as relatively low life expectancy, high neonatal deaths, high mortality rates from cardiovascular diseases, external causes of injury and poisoning, suicide and alcohol-related causes; a high incidence of TB, ranging from 1.7 times the EU15 level in Estonia to 2.8 times in Lithuania; and high death rates from motor vehicle traffic accidents relative to the EU15 (table 2). There was some variation across the three countries but none of the three was uniformly better than the other two. All were substantially worse on all of these indicators than the EU15, i.e. the EU before the accession of the 10 new members in May 2004. The reforms from 1992 onwards aimed to create modern public health systems with a focus on health promotion and non-infectious diseases prevention in addition to the prevention of infectious diseases.

View this table:
Table 2

Selected mortality and morbidity indicators in the Baltic countries and the EU, 1992/2005

1992–2005
EstoniaLatviaLithuaniaEU15aEU27
Life expectancy at birth (years)69.2/72.968.5/71.170.5/71.376.97/79.6b75.6/73.9
    Males63.5/67.362.6/65.464.9/65.473.5/76.7b71.98/75.3
    Females74.8/78.274.4/76.676.1/77.480.3/82.5b79.1/78.0
Neonatal deaths per 1000 live births11.9/3.311.1/5.611.6/4.14.3/2.9b5.5/3.3
Standard Mortality rate (SDR) per 100 000
    Disease of circulatory system683.9/498.2665.9/578.7560.4/562.8308.1/217.9b380.0/275.5
    Malignant neoplasm204.9/196.9197.9/193.8199.2/194.7199.9/175 b200.9/180.8
    External causes of injury and poisoning154.6/116.1169.7/131.5144.4/156.447.1/36.6 b56.4/42.7
    Suicide and self-inflicted injury32.6/18.735.1/22.536.5/37.011.97/10.0b13.5/11.2
    Selected alcohol-related causes164.4/158.3185.2/157.2169.0/190.893.8/58.4b108.4/67.6
Infectious diseases incidence per 100 000
    HIV0.59/46.10.04/13.00.14/3.55.3b/6.62.8/5.6
    TB26.3/38.736.5/65.343.2/61.415.5/9.75b22.4/17.6
Primary prevention (national health policy)
    SDR, motor vehicle traffic accidents20.8/12.731.3/18.225.1/22.613.1/8.6 b14.2/9.4
    SDR, trachea/bronchus/lung cancer44.6/36.641.6/35.639.8/33.740.0/36.7 b41.3/38.4
    SDR, chronic liver disease and cirrhosis5.4/21.78.0/15.311.1/25.915.7/11.9b17.99/14.8
  • a: EU15—the 15 Member States of the European Union prior to the May 2004 enlargement

  • b: Data for 1993/2005.

The analysis of health care indicators in Estonia, Latvia and Lithuania demonstrates both convergence and divergence across the three countries in key health characteristics and varying patterns in terms of catch-up, or its absence, in the direction of EU15.2 Between 1992 and 2005 all the three Baltic countries demonstrated marked decreases in neonatal deaths from rates ranging from 11.1–11.9 per 1000 births in 1992 to 3.3–5.6 in 2005 (table 2). The rate of improvement varied considerably across the three countries resulting in an increased variation in 2005 relative to 1992: Estonia made the most significant improvement with a decrease from 11.9 in 1992 to 3.3 in 2005 when the EU15 rate was 2.9. In contrast, the 2005 rates for Latvia and Lithuania were 4.1 and 5.6, respectively (table 2). As with its success in reducing neonatal mortality, Estonia achieved the greatest increase in life expectancy at birth—3.7 years—over the 13-year period from 1992 to 2005, compared to 2.6 years in Latvia and 0.8 in Lithuania. Even with this increase, life expectancy at birth in Estonia was only 92% of the EU15 average in 2005 and that of Lithuania and Latvia was 90% and this reflected a two percentage point decrease in Lithuania relative to the EU15 between 1992 and 2005.

Focusing on several standardized mortality rates in 2005 there is still very considerable leeway to be made up in each of the Baltic countries relative to the EU15, particularly in diseases of the circulatory system, in external causes of injury and poisoning, in suicide and self-inflicted injuries and in selected alcohol-related causes. It is noteworthy that Estonia has made most progress since 1992 in all of these mortality rates except in alcohol-related causes, in which Latvia achieved a higher reduction in mortality rates and had a marginally lower rate in 2005. Despite this reduction the Latvian and Estonian rates of 157 and 158 per 100 000, respectively in 2005 were 2.7 times the EU15 level (table 3). In contrast, Lithuania's rate of mortality from selected alcohol-related causes increased between 1992 and 2005 to 191 per 100 000, i.e. 3.3 times the EU15 rate in 2005. Lithuania, while starting from the best position in 1992, also had a marginal increase in its rate of mortality for diseases of the circulatory system by 2005 while Estonia had a 27% reduction and Latvia had a 13% reduction. Despite these reductions and the now premier position of Estonia amongst the Baltic countries its rate was still 2.2 times the EU15 rate in 2005, while the rates for Lithuania and Latvia were respectively 2.6 and 2.7 times the EU15 average (table 3).

View this table:
Table 3

Ratio of Baltic countries to EU15 in selected mortality and morbidity indicators (1992 and 2005) and coefficient of variation (cv) for selected indicators (1992 and 2005)

EstoniaLatviaLithuaniaEU15CV
Life expectancy at birth (years)
    19920.900.890.9276.97
    20050.920.900.9079.6a
Neonatal deaths per 1000 births
    19922.82.62.74.30.35
    20051.11.91.42.9a26.90
Standard Mortality Rate (SDR) per 100 000
Disease of circulatory system
    19922.22.21.8308.110.48
    20052.22.72.6217.97.13
Malignant neoplasm
    19921.01.01.0192.2a
    20051.11.11.1175
External causes of injury and poisoning
    19923.33.13.147.18.13
    20053.23.14.336.6a15.24
Suicide and self-inflicted injury
    19922.72.93.011.97
    20051.82.33.710.0a
Selected alcohol-related causes
    19921.72.01.893.87.35
    20052.72.73.358.4a11.31
Infectious diseases incidence per 100 000
HIV
    1992MinMin0.55.3
    20057.02.06.6
TB
    19921.72.42.815.524.30
    20054.06.76.39.75a26.05
Primary prevention indicators
SDR, trachea/bronchus/lung cancer
    19921.21.01.040.0
    20051.01.00.936.7a
SDR, chronic liver disease and cirrhosis
    19920.30.50.715.734.8
    20051.81.32.211.925.3
  • a: Data for 2004.

From an already high rate in 1992 the incidence of TB per 100 000 population increased in all three Baltic countries up to 2005. The increase was particularly marked in Latvia—78%—and in 2005 this was not only highest of the Baltic countries but was 6.7 times the EU15 average; Lithuania's rate was 6.3 times and Estonia's rate 4 times the EU15 average in 2005 (table 3). These increases contrast with a decrease of more than one-third in the EU15.

In contrast to the generally better performance of Estonia in selected mortality rates and the lesser increase in TB, HIV incidence in Estonia in 2005 was more than 13 times the Lithuanian rate, 3.5 times the Latvian rate and almost 7 times the EU15 average. It is noteworthy that the HIV rate in each of the Baltic countries was minuscule in 1992. While the EU15 increase over the same period was 24%, its rate was still relatively low in 2005. In Estonia, the HIV epidemics started to develop very rapidly in 2000. The group most affected was intravenous drug users (IDUs) sharing needles, but since then infection has started to spread sexually to non-IDUs.

In summary, examination of public health indicators over time in the Baltics indicates progress in several areas but with the exception of neonatal deaths no consistent catch-up relative to the EU15 (table 3). While progress has been made, the EU15 benchmark has improved even more. Relative dis-improvement is consistently evident in mortality from selected alcohol-related causes and chronic liver diseases and cirrhosis and in rates of TB and HIV. The most marked relative dis-improvement in relation to the two mortality rates is in Lithuania, while the greatest increase in the rate of TB is in Latvia and of HIV in Estonia. In contrast to Estonia and Latvia where mortality from external causes of injury and poisoning decreased, rates increased in Lithuania. As a result of these patterns we find increasing diversity across the Baltic countries in neonatal deaths per 1000, in external causes of injuries and in selected alcohol-related causes as measured by the coefficient of variation (table 3); the first of these due to the relatively greater improvement in Estonia and the latter due to the marked dis-improvement in Lithuania. The only evidence of convergence as measured by the coefficient of variation is in diseases of the circulatory system and death rates from liver disease and cirrhosis. Both can be explained by relatively greater changes in Estonia; on the positive side, a greater decrease in the incidence of diseases of the circulatory system; on the negative side, a greater increase in liver disease and cirrhosis death rates.

While Lithuania demonstrates an increased mortality from diseases of the circulatory system from 1992 to 2005, surveys do not report universally worsening health-related behaviour patterns. Surveys of representative samples of adults have been carried out every other year since 1994 in the Baltics and Finland. Results for Lithuania during 1994–2006 show positive trends in nutrition habits, an increase in prevalence of daily smoking among women, increased consumption of beer and stability in the consumption of strong alcohol and smoking among men.5 Comparative study of lifestyle factors indicates the lack of physical activity in all Baltic countries, but there is evidence that Latvian and Lithuanian women are approximately three times as likely to be obese as those from Estonia (17.4%, 18.3% and 6.0%, respectively).6,7 This diversity of findings suggest that more sharply focused studies are needed to detect real changes in health-related behaviour patterns.

Responses to public health problems

Since the beginning of the 1990s, all the three countries adopted numerous programmes to tackle these public health issues (table 4). Nevertheless, the scope and scale of these programmes and strategies differ. For example, Latvia's comprehensive Public Health Strategy adopted in 2001 entails a number of specific objectives and measurable targets.8 Lithuania also included quantitative targets in its 1998 Public Health Program9 and adopted a number of national programmes to tackle specific issues, such as mental health, and cancer and accident prevention. Estonia is the only country with a specific programme for research in Public Health. In determining success of public health measures, implementation and funding frequently have a greater impact than programme format. Little information is available on the implementation, financing and evaluation of such programmes in the Baltics. This section provides some examples of responses to selected public health issues, specifically, TB, alcohol consumption and HIV.

View this table:
Table 4

Public health programmes in the Baltic countries since mid-1990s

Public Health issueEstoniaLatviaLithuania
Alcohol and drugsNational Alcohol and Drug Abuse Prevention Program 1997; Estonian National Strategy on the Prevention on Drug Abuse 2005–12. This strategy is complemented by triennial action plans for implementation.The Latvian Alcohol Program 2005–08; State programme regarding drug use reduction 2005–08.State Alcohol Control Programme 1999–2010; National Strategy on Drug Addiction Prevention and Control 2004–08 and National Programme for Control of Drugs and Prevention of Drug addiction 2004–08.
TobaccoAnti-smoking Project started in 1996A Law on Tobacco Control in Latvia became effective from 1 July 2006. Excise tax on tobacco increased in 2004.National Tobacco Control Program
TBNational Tuberculosis Control Programmes 1998–2003 and 2004–07.Latvia's National Tuberculosis Control Program adopted in 1997 and DOTS-Plus project introduced in 1998.The National Tuberculosis Prevention and Control program 2003–06.
HIV/AIDSThe National HIV/AIDS Prevention Programme 2002–06 and 2006–15HIV/AIDS prevention program 1999–2003; Programme for limiting spread of HIV/AIDS adopted by the Cabinet for 2003–07HIV/AIDS Prevention Programme 2003–08.
Accident preventionNational Traffic Safety Program 2003–15 adopted in 2003.Targets 3 and 10 of Public Health strategy and Road Traffic Safety Program 2007–13 aim to tackle accident preventionState Programme on Accidents Prevention and Control 2000–10.
Cardiovascular diseasesNational Strategy for Prevention of Cardiovascular Diseases 2005–20One of the targets (8th) of the Public Health Strategy adopted in 2001 is to reduce mortality due to cardiovascular diseases by 20% in people under 65 years of ageCardiovascular Disease Prevention Programme 1999–2005
Mental healthMental Health Policy Framework adopted in 2003The 6th aim of the Public Health strategy is to improve mental health by 2010State Programme on Mental Disease Prevention (1999) Suicide Prevention Programme for 2003–05. National Mental health strategy adopted in 2007
Cancer preventionCancer prevention programme 2007–15. Estonian Health Insurance Fund funds screening services for cervical and breast cancerThe eighth target of the Public health strategy aims to reduce mortality from visually sited cancers among population under 65 years of age by 15%; and mortality from lung cancer by 10%State Programme on Cancer Prevention and Control 2003–10
Child healthProgramme 1997–2007 and the National Child and Adolescent Health ProgrammeThe third and the fourth targets of the PH Strategy aim to improve child health by 2010. Maternal and Infant Health Care Strategy was adopted in 2001 and has implementation plan for 2004–07. Cabinet adopted the Children-friendly Latvia 2004–07 programme in 2004Mother and Child Health Programme 2003–05
Research and developmentNational Programme for Health Research and Development 1999–2009No specific national programme adoptedNo specific national programme adopted

TB has been one of the major PH issues in the Baltics in the post-Soviet era; its incidence has increased steadily since the beginning of the 1990s to a peak in 1998 when it reached 59.2, 85.0 and 96.5 new cases per 100 000 population in Estonia, Lithuania and Latvia, respectively. By 2005, the incidence was ∼30% lower (38.7%, 65.3% and 61.4%, respectively) due to effective interventions. The common intervention was the WHO recommended DOT (Directly Observed Treatment) which greatly increased cure rates. Despite the effectiveness of these post-1998 interventions, the magnitude of the TB problem is reflected in the higher incidence and prevalence in all the three countries in 2005 than in 1992 (table 2). This points to the influence of underlying socio-economic problems, financial constraints and service delivery problems.

Alcohol control programmes have faced difficulties in all the three countries. In Lithuania, numerous organizational and legislative measures were introduced to reduce alcohol consumption and mortality from liver cirrhosis and mortality associated with alcohol-related accidents by 2009. The State Agency on Tobacco and Alcohol Control was established in 1996. Nevertheless, the consumption of alcoholic drinks, including by teenagers, has increased since the mid-1990s. The reasons include the lack of vigorous implementation of relevant legislation and poorly defined functions of the above-mentioned agency and other responsible institutions,10,11 the weak position of NGOs and the very strong position of the alcohol industry.12 Similarly, in Estonia, where the institution responsible for alcohol control is the Ministry of Social Affairs, the turnover in the alcohol trade has sharply increased and prices have tumbled since the late 1990s. In Latvia, the Health Promotion State Agency is responsible for the implementation of tobacco and alcohol policies but it is estimated that around 30% of all alcohol consumed is purchased in the illicit market. The influence that the industry exerts on politicians and the media constitutes a major problem in all of the Baltic countries.12

In 1995, Lithuania started implementing drugs harm reduction programmes, which contributed to slowing the spread of HIV/AIDS. The Ministry of Health approved the launch of experimental methadone substitution treatment programmes, and these are currently implemented in five cities. In 1997, syringe/needle exchange programmes were introduced.13 The preventive measures on HIV/AIDS implemented in Estonia among IDUs (rehabilitation, methadone programme) cover 5–15% of those who need them and exchange of needles covers about 35–40%. It is estimated that halting the process would necessitate increasing the percentage of IDUs involved in preventive measures (counseling and needle exchange) to at least 60–70%.14 In Latvia, HIV incidence remained low until the end of 1997. The incidence peaked in 2001 with 807 new HIV cases registered; since 2004 the reported number of newly diagnosed cases has been relatively stable. Since 1998 the main mode of HIV transmission has been through injecting drugs. The harm reduction programmes in Latvia are associated with the decline in the rate of newly registered HIV infections among IDUs. During 2002–03 outreach/counseling centers were established in each of 10 municipalities in order to provide diversified services, such as needle exchange, outreach, education and others. This initiative reflects successful cooperation between central and local levels.15

Discussion

Starting from similar structures in the early 1990s the health systems and in particular the public health systems in all the Baltic countries have gone through significant reforms in the 1992–2005 period. These reforms have resulted in broadly similar health systems. They have also resulted in progress in some outcome indicators but little evidence of catch-up to the EU15 level in most key indicators by 2005. While considerable work is needed in each of the countries to bring the outcomes close to the EU15 levels there are some significant variations across the three countries and these may afford useful insights in relation to possible future progress.

As was mentioned earlier, there is very limited information on the evaluation of the performance of public health programmes in the Baltics in general although there are some positive initiatives particularly in Estonia and to a lesser extent in the other two countries. In 2006, the Estonian Health Insurance Fund initiated evaluation of the performance and management of disease prevention programmes. In 2006, three projects were evaluated and recommendations were made for changing the current project objectives, activities and management processes.16 Despite the commitment to evaluation in Estonia, the evaluation of health programmes and projects is often complicated because the objectives have not been clearly formulated and measurable outcomes are not specified.17 The overall decline in perinatal mortality in Estonia since 1992 has been attributed to establishment of modern equipped neonatal intensive care units in reorganized perinatal centres and introduction of a neonatal transportation system.18 Well-developed primary health care has improved access to and the range of health services and contributed to the improvement in average life expectancy in Estonia.

In Lithuania, evaluation and research on public health issues is scare, but some analytical insights are provided in the official audit reports. State Audit assessed achievement of the objectives of the National Public Health Strategy and concluded that this strategy was only partially implemented. Among the reasons are insufficient separation between policy development and policy execution, lack of leadership and the institutional capacity of the State Public Health Service, which has been the principal institution responsible for the National Public Health Strategy.19 Another report on strategic planning in the Lithuanian health sector indicates that none of the six multisectorial programmes coordinated by the Ministry of Health had explicit evaluation criteria in 2005 and those listed in the 2006–08 work plan have not adequately reflected programme outcomes. Lack of efficiency in some public health programmes was noted, e.g. financial resources were allocated to the accident prevention programme without thorough planning of its second phase.20

In Latvia, the Public Health Strategy envisaged a high level Inter-Ministerial Coordination Council that would oversee its implementation. This was not established, and there is a lack of capacity and financing to provide effective monitoring and evaluation of progress.4 In Latvia, corruption and tax evasion have been perceived as important problems: it was estimated that unpaid income and social taxes constitute 15–40% of GDP.21 The missing tax funds have had negative consequences for the health sector.

The Corruption Perception Index (CPI) ranks countries by their perceived levels of corruption as determined by expert assessments and opinion surveys; it ranges from 1 (most corrupt) to 10 (least corrupt). In 2005 the CPI was 4.2 in Latvia, 4.8 in Lithuania and 6.4 in Estonia; the index has improved since 2001 in Latvia and Estonia while relatively stable in Lithuania.22 The CPI tends to co-vary with level of economic development as reflected in GDP per capita and this is evident in the Baltics where Estonia has had the highest GDP since the beginning of the 1990s;2 in 2004 it was 1.4 times higher than in Latvia and 1.3 times higher than in Lithuania.23 Results of the social audit of the health sector of the three Baltic states carried out in 2002 indicate that Estonia had least corruption, Latvia was in the middle and Lithuania evidenced the most unofficial payments and the greatest mistrust of the system.24

Other socio-economic and political factors, such as poverty and political instability, have had a negative impact on population health especially on so-called ‘social diseases’ like TB. In Latvia, the average monthly income per household member is below the poverty line, indicating that more than half of Latvia's population subsists on incomes below the minimum subsistence level.4 In terms of politics, the Baltic countries have faced frequent government changes during the last 15 years and this caused the lack of sustainability of some public health policies. Latvia and Lithuania had 14 changes of government up to 2008 while Estonia had nine.

Apart from neonatal mortality where progress from 1992 to 2005 has been generally impressive, and TB, chronic liver disease and cirrhosis where the incidence, and in the latter two mortality, have moderate progress is evident for key public health indicators although cross-national variation on several indicators is marked. Decision makers in the Baltic countries focused on regulation and legislation of public health, but paid little attention to evidence-based interventions or to evaluation of the public health programmes. Implementation of these programmes has been hampered by the lack of financial and/or technical resources in some countries, weak intersectoral cooperation and strong industry pressure on alcohol and tobacco policies.

If significant progress is to be made, the Baltic states will have to address diverse public health issues including the risks factors for cardiovascular diseases, TB, AIDS and high alcohol consumption. In order to do so, public health interventions should target the most relevant population groups, such as lower socio-economic groups in the case of TB. In terms of alcohol policies, they should be able to tackle drinking patterns and the use of illegal alcohol and focus on the general population aged over 15. Public health specialists will have to work with professionals from other areas in designing and implementing evidence-based policies if public health indicators are to be improved in the Baltics. Managerial capacity and sufficient finance are needed for successful programme implementation. Lithuania and Latvia need to enhance social trust and address high level corruption and unofficial payments. Our analysis can serve as a baseline for the development of intersectoral interventions to tackle public health issues in Estonia, Latvia and Lithuania.

Acknowledgement

Authors are grateful to Dr med. Jautrite Karaskevica for providing information on Latvian health care system.

Conflicts of interest: None declared.

Key points

  • Since the beginning of the 1990s, public health development in Estonia, Latvia and Lithuania shows some similarities and some important differences.

  • Public health reforms in Baltic countries show little evidence of catch-up to the EU15 level.

  • If progress is to be made, the Baltic countries will have to introduce evidence-based public health interventions, enhance social trust and managerial capacity, address corruption and tackle poverty.

References

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