Intended for healthcare professionals

Analysis Health Systems Perspectives

The Baltic states: building on 20 years of health reforms

BMJ 2012; 345 doi: (Published 23 November 2012) Cite this as: BMJ 2012;345:e7348
  1. Ewout van Ginneken, senior researcher1, honorary research fellow 2,
  2. Jarno Habicht, WHO representative3,
  3. Liubove Murauskiene, director4,
  4. Daiga Behmane, member of the board5,
  5. Philipa Mladovsky, research fellow 26
  1. 1Department of Health Care Management, Berlin University of Technology, Strasse des 17 Juni 135, Berlin 10623, Germany
  2. 2 European Observatory on Health Systems and Policies, rue de l’Autonomie 4, B-1070 Brussels, Belgium
  3. 3WHO Country Office in Republic of Moldova, World Health Organization, 29 Sfatul Tarii Street, MD2029 Chisinau, Republic of Moldova
  4. 4MTVC (Training, Research and Development Center), Antakalnio 22B, Vilnius LT-10305, Lithuania
  5. 5Latvian Association of Health Economics, 85-7 Brivibas Street, Riga, LV1001, Latvia
  6. 6LSE Health, London School of Economics and Political Science, London WC2A 2AE, UK
  1. Correspondence to: E van Ginneken ewout.vanginneken{at}
  • Accepted 18 October 2012

The Baltic States are recovering from a crisis as deep as Greece’s. Van Ginneken and colleagues suggest that the crisis has provided an opportunity to improve efficiency and equity, although concerns about financial sustainability and the impact on public health remain

The Baltic states Estonia, Latvia, and Lithuania regained independence in the early 1990s in the aftermath of the dissolution of the Soviet Union. Since then, they have had a rocky path to health reform. The reforms have been aimed at making a clear break with the Soviet-style Semashko model, which was characterised by central planning and universal access but which suffered from inefficiency, hospital overcapacity, and poor healthcare.1 Early reforms, similar across all the Baltic states, focused on improving quality, efficiency, and geographical and timely access to healthcare. Yet differences in size, language, politics, economy, and culture (fig 1) perhaps explain variations in the implementation of the reforms. In recent times, a difficult economic climate has required some tough austerity measures to balance public budgets. We discuss these reforms, the impact of the global financial crisis, and some challenges for the future.

Fig 1 Often viewed as one entity, the Baltic states portray some important differences

Decentralising and recentralising financing arrangements

After independence, all three Baltic states adopted social health insurance systems. For these countries, with their deep rooted distrust of government, a system in which organisational and health financing arrangements lay largely outside the state sector was an attractive prospect.2 Additionally, by introducing a purchaser-provider split, they hoped to increase transparency and efficiency. Finally, in a fragile economic environment, earmarked payroll tax was seen as a more stable funding source than general tax. However, in all three states, the decentralisation of the financing system resulted in inefficient and fragmented allocation of resources and was followed by a gradual recentralisation. As …

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