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«The management of health systems in the EU Member States - The role of local and regional authorities The study was written by Progress Consulting ...»

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A distinction is made between primary, secondary, and tertiary health care, and emergency medical care. General practitioners, usually working together with a nurse and an assistant, provide primary health care; GPs function as gatekeepers to secondary health care. A referral from a primary care physician or a specialist is also needed to access diagnostic examinations and ambulatory surgery services, but it is not required to access some specialists such as, for example, paediatric services. Secondary health care is provided at ambulatory (outpatient) level, emergency medical care level, through day-patient facilities or at regional and local hospitals. Tertiary care is provided in specialised medical institutions.

Health care services are delivered in a variety of institutional settings and legal forms. Providers may be independent or employed by, among others, local governments. The condition for patients being able to receive services is that providers have an agreement in place with the Health Payment Centre.

In recent years, several structural changes have taken place in the health sector, implying a restructuring of state agencies and reduction of personnel (the staff of the Ministry of Health was reduced by 43% in 2009).

Hospitals were also drastically re-organised: those providing emergency care were reduced from 59 to 20 in 2010; some 41 hospitals were progressively closed and transformed into health care day centres. In 2009, all planned surgery and other treatment was halted, with the exception of emergency cases, and performed only if patients could afford to pay. Hospitals may be state or district/municipality owned, or private. District/municipal hospitals have the status of a limited company or municipal agency. Current legislation does not attribute a specific role in health care to local government;

they no longer bear financial responsibility, their main responsibility being to ensure access to health care services.

The State Agency of Medicines of Latvia is a Regulatory Authority under the MoH, responsible for authorisation, monitoring, inspection and market regulation of medicines. Distribution is through pharmacies or wholesalers.

Medicines are subject to full or partial (75% or 50%) reimbursement depending whether they are vital for the patient’s life, or refer to chronic or acute diseases.

Finance and health care expenditure The level of subsidy for health care by public financing through general taxation is determined by the state budget law. The funds for health derived from national revenue represent one of the two main sources of funding, the other being upfront payments by patients that include user charges for all statutorily financed services and direct payments for those services that are not financed by the state and are specified in the so-called ‘negative list of benefits’. Public expenditure on health was slightly over 50% of total health expenditure in 2005 (52.6%), 46.6% being the share contributed by upfront payments.

In 2010, reductions in or abolition of patient fees and co-payment levels were introduced for those on low incomes. Payments for voluntary insurance schemes sank when, in 2009, the Prime Minister prohibited the buying of insurance policies for civil servants. All funds devoted to health expenditure are pooled through the Health Payment Centre.


- Curkina I. (2009), Healthcare sector hit by recessionary cutbacks, EIROnline

- Ministry of Health of the Republic of Latvia website

- Bite I. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care:

Latvia. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms

- Tragakes E. et al. (2008), Health Systems in Transition, Vol. 10 No.8, Latvia: Health system review, European Observatory on Health Systems and Policies.

LITHUANIA Main characteristics of the Lithuanian health care system ►Centrally regulated but with several executive responsibilities delegated to local authorities (municipalities) ►Nearly universal coverage based on compulsory health insurance ►Mainly public financing of health care – out of earmarked taxation and state budget ►Mixed service provision – public and private Structure of the system and responsibilities The health care system of Lithuania is undergoing a restructuring process as outlined in the Plan of Measures for Implementation of the Third Stage of the Restructuring of Health Care Institutions and Services, approved by the Minister of Health at the end of 2009. In addition, in 2010, county administrations were abolished. These two circumstances have impacted, and continue to do so, on applying responsibilities, ownership and implementation mechanisms.

At the central level, the Ministry of Health is responsible for the overall performance of the national health system. It develops policies, issues regulations, oversees the licensing of the medical and pharmaceutical sectors, and determines the development of public health care infrastructure. Under the Ministry of Health, but also accountable to the Ministry of Finance, is the National Health Insurance Fund (NHIF). The NHIF is a state authority providing the compulsory health insurance and coordinating the activities of five territorial health insurance funds: Vilnius, Kaunas, Panevėžys, Šiauliai, and Klaipėda.

Since 1997, Lithuania has had a Compulsory Health Insurance Fund that represents the basis for the financing of the public health system; through the territorial health insurance funds contracts are concluded with health care service providers (institutions and pharmacies); on the basis of these contracts, providers are paid the cost of rendered services through the funds.

Representatives of local authorities sit on both the Mandatory Health Insurance Board, through an association of municipalities, and on each of the supervisory boards of the territorial funds, through members of municipality councils. The Ministry of Health has other several institutions under its control, including eight hospitals and clinics.

The governance structure of health care has changed since July 2010, when the county administrations were abolished and their responsibilities taken back by the Ministry or delegated to municipalities. Municipalities are responsible for primary care, including decisionmaking, delivery of services and supervision. They also run some small and medium-sized hospitals, or have subordinated secondary and tertiary institutions;, they are also responsible for the implementation of local health programmes and for activities related to the improvement of public health.

Delivery of services Insured individuals have access to a range of services including,primary outpatient, specialised outpatient and in-patient health care, first aid, nursing care, screenings, rehabilitation, and medicines. Primary health care is provided through 452 state facilities such as general practitioners’ offices, ambulatory clinics, or polyclinics (if in bigger urban areas), or medical posts in schools (in rural areas). GPs are publicly employed or work under contractual arrangements, but private practice is also common with some 1,284 private institutions delivering primary health care. Secondary care is provided through general and specialised hospitals.

Patients are free to choose the doctor, the specialist and the institution; the GPs have a gate-keeping function to secondary care but access to specialists and private health professionals is possible also without referral.

Finance and health care expenditure In 2008, the publicly financed health system covered all residents for emergency care and about 96-97% of the population; in the same year, about 75% of total health expenditure was public, the rest being private. Public expenditure was for mandatory health insurance reimbursements (87%), health programmes (7%)

and state investment programmes (6%). Sources of public funding include:

earmarked taxation (since 2009), health insurance contributions, state and, to a lesser extent, local budgets. Private expenditure is mostly represented by upfront payments.


- Kiskiene A. et al. (2010), Country Brief: Lithuania, eHealth Strategies

- Jankauskien D. and Medaiskis T. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Lithuania. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms

- NHIF website

- Kacevičius G. (2010), Mandatory Health Insurance system in Lithuania: an overview LUXEMBOURG Main characteristics of the Luxembourg health care system ►Centralised and regulated ►Providing nearly universal coverage, through statutory public health insurance and care insurance ►Mainly public financing of health care – out of state budget and taxation of gross earnings ►Mostly public service provision Structure of the system and responsibilities The Ministry of Health is responsible for the regulation, planning and organisation of the national health care system. Additionally, it takes responsibility for funding, authorising service providers, implementing or delegating implementation, and for monitoring and evaluation.

Health services are provided on the basis of two types of insurance, both under the responsibility of the Ministry of Social Security: (i) universal health insurance (Caisse Nationale de Santé - CNS), funded by the state, the active population and their employers (5.4% of gross earnings); and (ii) compulsory (long-term) care insurance, financed by the state and individuals. Public health insurance is mandatory for all economically active persons, including their family members; it gives access to a comprehensive package of services.

Provision of primary care is not regulated. The hospital and pharmaceutical sectors are regulated, including the number of pharmacies. All health providers have to be authorised by the Ministry of Health in order to practice. Fees for the provision of services are negotiated between trade unions or professional associations and employers (in case of secondary care settings such as hospitals) or the national health insurance, in the case of primary care. Patients pay the cost of the services (upfront payments) and are later reimbursed in the region of 80% to 100% of the cost.

A reform of the health insurance and of the organisation of the health care system is currently under consideration.

Delivery of services Services are delivered through primary care providers, hospitals (private and non-profit), longterm care settings, and specialists. The non-profit hospitals are owned and managed either by local authorities or foundations and religious orders.15 Patients are free to choose the doctor, the specialists, and the hospital. There is no referral system in place. The hospital sector is divided into three geographical areas and includes five general hospitals and six specialised institutions.

–  –  –

Finance and health care expenditure Public expenditure covers most health expenditure (90.1% in 2006) the rest being covered by private expenditure which is mainly provided by upfront payments and, to a lesser extent, payments for/to? private insurance schemes.

The health insurance works on a reimbursement basis; only services rendered in hospitals are in kind, with the exception of doctors’ bills which still have to be paid by patients.

Funding of hospitals is via national health insurance; investment costs are contributed by the state to the tune of 80%, the rest being covered by national health insurance. Long-term and palliative care is financed by the compulsory care insurance (‘assurance dépendance’).


- Consbruck R. (2010). The health system of the Grand-Duchy of Luxembourg in 2010, Ministry of Health, Luxemburg

- Hohmann J. (2010), Annual National Report 2010 – Pensions, Health and Long-term Care: Luxembourg. ASISP: Analytical support on the Socio-Economic Impact of Social Protection Reforms.

MALTA Main characteristics of the Maltese health care system ►Centralised and tightly regulated ►Providing coverage free of charge for residents at the point of service ►Mainly public financing of health care – out of taxation and national insurance ►Mixed service provision – public and private

Structure of the system and responsibilities

Health care in the public sector is centralised and tightly regulated, with the Public Health Act the most relevant piece of legislation. The Ministry of Health, the Elderly and Community Care is responsible for health policies and planning as well as for the financing and provision of publicly-funded health care services. The Ministry’s Health Care Services Division encompasses three departments: Elderly, Primary Health Care, and Government Health Procurement Services. The Primary Health Care department takes responsibility for the provision of services at primary health care level and for the coordination and organisation of a Government Health Centre system.

Delivery of services Statutory primary care is provided through eight Health Centres (Centri tasSacca), some of which have one or two satellites. This statutory system delivers general practitioner and nursing services, as well as some specialist services such as immunisation, antenatal and postnatal clinics, diabetes clinics, ophthalmic clinics, paediatric clinics, dental services, etc. Patients are requested to attend the Centre serving their locality of residence. Health Centres do not have a strong gate-keeping function, leading to an excessive use of secondary care services. Secondary care and tertiary care are provided through public hospitals. There are currently eight public hospitals in Malta, the most important, opened in 2007, being the Mater Dei hospital in Msida.

Provision of medical services at the Health Centres and public hospitals is free of charge but patients are expected to make upfront payments for outpatient pharmaceuticals. Some vulnerable groups (low income and those with chronic diseases) are exempted from these payments.

The private sector is gaining in importance in the delivery of health-related services. There are private general practitioners and specialists as well as a number of private hospitals, clinics and other facilities providing private health care. There is both a lack of regulation of private health care practice and of coordination between public and private providers.

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