Given the wide scope of the policy under development in a country in transition, the equity in health issues are recognized as part of the overall health policy for Lithuania (13,14). The need to promote equity is clearly demonstrated by inequalities in health status that are well documented in Lithuania (see Lithuanian health report – 1990’s (3), pp. 12–14). Nevertheless, the equity issue in Lithuania, probably similar to many other post-socialist countries, is not popular for political reasons. The main reason for this is the difficulty in returning to the equity challenge after a long period of declarations under the old regime about equity and solidarity and the experience of “equity in poverty”.
This problem is further complicated by the ongoing process of privatization. This is why the present policy framework is addressing equity mainly by providing equal accessibility to health services for the total population with priority given to the most vulnerable groups (mothers and children, disabled people and elderly people). At the same time, some signs indicate that the situation might be improving rapidly, since various nongovernmental organizations and interest groups are already putting considerable pressure on the Government, municipal authorities and health services to take into account the needs of these disadvantaged groups. One example is that the existing legislation provides a good basis for requesting actions; for example, the law on integrating disabled people into society provides good opportunities to put considerable pressure on national, regional and local authorities. To support the scientific evidence for taking issues of inequalities in health seriously, the research group from Kaunas Medical Academy is carrying out a research project designed to study health inequalities in Lithuania in more depth. The issues of lifestyles, environment and accessibility to health care are being taken into account.
Participation
Lithuania has the privilege of having a solid database that combines the health statistics collected routinely at the national, regional and local levels with the data from research projects carried out on representative population samples. The national health data extend back to the 1930s, and some data from the research projects are available for at least the last two decades. Paradoxically, this has not influenced the development of health policy or enabled informed participation in decision-making. One explanation
for this might be that, until the Soviet regime collapsed, substantial health or health-related information (especially at the national level) was not accessible to researchers, health administrators or the public.
This did not allow the long-term trends in health status in Lithuania to be assessed properly, discussed openly or compared with similar health indicators and their trends in western European countries.
As mentioned earlier, the development of a new national concept of health for Lithuania, which was adopted by Parliament in October 1991, is a starting-point for national health policy formulation. The health professions initiated the development of this concept, and representatives from all levels (national, regional and local) have participated actively in initiating this process. After a task force formed by the Lithuanian Medical Association and chaired by representatives of Kaunas Medical Academy prepared the first draft, a national dialogue started, with the full text of the concept being published in Atgimimas, a very popular weekly newspaper at that time.
A special effort was made to involve all health professional associations in this consultation process as well as non-health government and nongovernmental organizations and interest groups, such as other ministries, municipalities, charitable organizations, sports and leisure organizations and clubs, health clubs, the Catholic Church and the mass media. This process was greatly facilitated by the active role of the Parliamentary Health Commission, which assisted in organizing the dialogue nationwide. Neverthe-less, national politicians and experts had the major responsibility and accountability for the final version of the document.
One of the most serious problems in formulating the major principles of the new national concept of health was the apparent intention of the medical profession to limit the concept itself and the related dialogue mainly to the functions of the medical profession and health care structures. This arises from a restricted medicalized perception of health and consequently concentrates on more or less medical approaches to solving health problems. As might be expected, the involvement of sectors other than health care in the national dialogue on health policy and strategy was a decisive component of moving towards a much broader concept of health and the approaches to dealing with this. The group of professionals that was most opposed to and obstructive of health policy development was the newly established Association of Privately Practising Physicians.
The general public traditionally has had limited interest in health policy issues, as this has been considered the responsibility of the politicians. Fortunately, this attitude is changing; one way is the growing numbers of nongovernmental organizations.
The Parliamentary Health Commission played a decisive role in a parliamentary health discussion day in November 1995 in collaboration with WHO. A large number of members of parliament took part in discussing the main health challenges, and the public galleries were packed with representatives of nongovernmental organizations, municipalities and other local groups. The whole discussion was broadcast on radio, and excerpts were shown on television.
Many political parties participated both in the first National Health Policy Conference and in the parliamentary discussion. This willingness to engage in open dialogue and a search for a degree of consensus on health issues has been an important feature of the post-socialist era.
International opinion, standards and expertise have played a very important role in helping to achieve acceptance of the broader concepts of health both among the health professions, as well as in the public at large. WHO has played a decisive role in this. Lithuania started to formulate health policy as a subnational entity under the Soviet regime. Later, the first National Health Policy Conference was organized in 1993 and the first Lithuanian health report was published under the stimulating role of the Regional Office for Europe and with its considerable help.
Lithuania is now serving as a test case for the formulation of a comprehensive health policy extending to 2005 by collaborating with WHO to network the networks. Those involved in the WHO Regions for Health Network, Healthy Cities project, Health Promoting Schools project, Health Promoting Kindergar-tens project, Health Promoting Hospitals project, Baby Friendly Hospitals project and CINDI programme are collaborating in formulating the draft policy document and are discussing their potential role in implement-ing the policy. Thus, not only strong synergy is expected as the various networks collaborate but also wider participation, ownership and commitment from many more groups and prospective partners.
Intersectoral policy
Fortunately, the new national concept of health clearly spelled out the major principles of a policy for health for all. This gave numerous opportunities to initiate health policy implementation parallel to parliamentary discussion on health legislation. Joint action plans have been elaborated by the Ministries of Health and of Education and Science on a national programme for healthy schools; by the Ministries of Health and of Environment on a national programme for environmental health protection; by the Ministries of Health and of Social Security and Labour on a national programme for the integration of disabled people in society; and by the Ministries of Health and of the Interior on a national programme for preventing traffic accidents. National action programmes with intersectoral involvement have also been prepared, discussed and approved by various authorities on tobacco or health, hypertension control, healthy nutrition, prevention of AIDS and prevention and control of cardiovascular diseases.
Although these programmes have clearly defined objectives and targets as well as mechanisms for implementation, the planned implementation suffers considerably because of lack of resources. Another obstacle is the resistance of old structures to planned changes. A narrow and excessively medicalized, hospital-based and physician-centred model of health care services often continues to be the focus of attention. This means that further efforts are needed to keep forthcoming changes in the Lithuanian health system closer to the health for all principles and approach. Enhancing the health promotion and disease prevention activities in health services will rely heavily on the experience accumulated in the CINDI programme(15).
The reality is that intersectoral collaboration for health still remains a delicate issue in Lithuania.
Regardless of the general acceptance that other sectors of society are important for the health of the population, no effective mechanisms to implement this intersectoral collaboration have been in place until recently. Many of the limited-scale activities referred to previously have occurred at the local level and have been based on the enthusiasm of certain individuals or interest groups.
A somewhat more systematic approach was developed in the CINDI experimental areas and more recently in Kaunas within the Healthy Cities Project, which is now developing a healthy cities network in Lithuania.
The research teams, mainly from Kaunas Medical Academy, disseminated information. The Academy was also involved in health intervention projects that helped to publicize the concepts of intersectoral collaboration for health. The ongoing process of developing new legislation in Lithuania has consider-ably helped to involve other sectors in setting common objectives for health. The Law of the Health System, adopted by Parliament in 1994, has considerably strengthened the potential for intersectoral collaboration for health. For example, this Law stipulates that a National Board of Health reporting to Parliament is to be established on which all sectors of society should be represented. At the level of government, an Intersectoral Executive Committee for Health is to be established, supported by similar structures at the municipal level. The adopted laws on alcohol control, tobacco control and consumers’
rights, which were either guided or drafted by those involved in health policy formulation (such as the group from Kaunas Medical Academy), provide a good legislative basis to move more aggressively towards intersectoral collaboration for health. During the 1995 parliamentary health discussion, a number of ministers other than the Minister for Health took part and showed clearly that they recognize their responsibility for health.
Putting health on the agenda of other sectors is still not easy. For example, a multinational tobacco corporation (Philip Morris, which entered Lithuania in 1993) was the major obstacle to the adoption of the Tobacco Control Law, which gives priority to the health needs of the people.
The Public Health Faculty at Kaunas Medical Academy was established in 1994. This is an important factor that is already contributing to strengthening the process of developing intersectoral policies for health and is planned to contribute much more in the future. The faculty will conduct bachelor degree undergraduate training programmes covering such important areas as health planning, health system development, health education and environmental health. The postgraduate School of Public Health, which all those having a university degree will be eligible to enter, is planned to be organized as a consortium of universities, academies and institutes in Kaunas. It is hoped that this structure can provide information and research support to find further evidence of the role of various risk factors on the level of health of the population. It will assess the effectiveness of interventions and will, therefore, strengthen the development and implementation of intersectoral policies for health.