Public health bureaus : new players in health improvement in Lithuania

3 Institute of Public Health, Faculty of Medicine, Vilnius University, Vilnius, Lithuania Particular emphasis in the development of the public health care system in Lithuania was put on strengthening public health at the municipal level. This paper aims at investigating the possibilities and barriers of the public health reform in Lithuania by analyzing the experience of establishing public health bureaus as the major players in public health development at the municipal level. The Lithuanian National Public Health Strategy and Action Plan have been adopted by the Government in 2006. Ministry of Health prepared legal acts and programmes that encourage local authorities to establish public health bureaus. By the end of 2010, 32 municipal Public health bureaus were set up. The core main functions of the bureaus are public health promotion, monitoring public health and child health care. The first steps of the bureaus were complicated by the lack of well-developed strategies of action and local support, as well as by financial challenges. For strengthening the position of the bureaus in society, benefits of these newly established institutions should be widely presented to the public; sustainable financing mechanisms and a focus on intersectoral cooperation, integrating public health into primary health care are needed; also, human resource development should be foreseen. In spite of the rather challenging beginning, bureaus are starting to provide means by which local governments, in partnership with the service providers, other stakeholders and the community can plan and implement public health services and programmes and play a significant role in improving the health of population.


INTRODUCTION
Lithuania has experienced enormous political, social and economic changes during the last decades, shifting from being a highly centralized republic of the Soviet Union to an independent state with a newly developing market economy.The social and economic reforms taking place in Lithuania for the last twenty years have been negatively affecting the demographic processes and public health.The aging population, deteriorating health and growing in-equalities indicate the necessity to accelerate the reform of the public health system in the country.It is acknowledged that the patterns of public health have changed, and that there is an urgent need for new strategies and structures to reflect this change.It is increasingly recognized that greater efforts are needed to prevent ill health and creating wellbeing, especially among those who are most disadvantaged.Thus, developing health-supportive environments needs strengthening the community's capacity to achieve better health.This process involves developing sustainable skills, organizational structures, resources and commitment to improvement in health and other sectors.In the public health policy environment, an increasing emphasis is placed on developing public health services on the local level.It is expected that development of the public health system at Correspondence to: Prof. Ramunė Kalėdienė, Dept. of Health Management, Faculty of Public Health, Academy of Medicine, Lithuanian University of Health Sciences, Mickevičiaus Str. 9, LT-44307 Kaunas, Lithuania.E-mail: socmed@kmu.lt the municipal level will improve the capacity of organizations and communities to promote health in Lithuania.
This paper aims at investigating the possibilities and barriers of the public health reform in Lithuania by analyzing the experience of establishing public health bureaus as the major players in public health development at the municipal level.

CURRENT CHALLENGES TO NATIONAL PUBLIC HEALTH
The population of Lithuania, which is relatively homogeneous in terms of cultural factors such as nationality or religious affiliation, is gradually decreasing.The rapid decrease in the number of population is caused by the low birth rate unable to ensure the changeover of generations, high flows of emigration, and high mortality.The increase of the population in the country remains negative since 1994 and in 2009 was -1.6 per 1000 population.In 2009, there were 3339.4 thousand inhabitants in Lithuania.With the decreasing number of the population, the trend continues to be directed towards aging.At the beginning of 2010, 20.9% of inhabitants were aged 60 and over.In 2009, mortality in Lithuania was 12.6 per 1000 population.The age-standardised death rate for males was nearly twice as high as for females.In 2009, the life expectancy of Lithuanian males was 67.5 years, i. e. 1.2 years longer than in 2008, while that of females was 78.6 years, i. e. 1 year longer than in 2008 (1).Thus, there is still a significant difference in female and male life expectancy (more than 11 years).The life expectancy of males born in Lithuania is among the shortest in the European Union, and that of females is also shorter than in the majority of the EU countries (2).The structure of the causes of death has remained unchanged throughout the recent years.More than half of all deaths (55.4%) occurred due to cardiovascular diseases; 19.3% of the population died from cancer.Even though mortality from external causes decreased by 12.9% in 2009, mortality from these causes is extremely high, particularly among young and middleaged groups of populations.Suicide is the major external cause of death.In spite of the recent positive trend, suicide mortality remains among those highest in Europe and is considered as one of the major public health challenges in Lithuania, requiring complex prevention measures.Mortality from diseases of the digestive system, especially from the alcoholic liver disease, liver cirrhosis and fibrosis, is rapidly increasing.Infant mortality, which is a very important indicator in assessing population health, social and economic development, has been decreasing in Lithuania since 1993 and was 5.0 per 1000 live born in 2009 (1).Economic and social reforms in the country accentuated the relative concentration of economic activities, social services, and educated population, and therefore contributed to the stratification of health possibilities between urban areas and rural periphery.The age-standardized overall mortality of the rural population consistently exceeds that in urban areas.The most pronounced mortality inequalities are observed among young and middle-aged groups of population.In 2008, life expectancy for rural males was shorter than for urban ones by 3.5 years, while among females this difference was 2.5 years.Considerable inequality in health depending on the level of education is another important public health challenge, which requires particular attention (3,4).The large educational and urban / rural and educational inequalities in mortality are indicative of a greater social and psychological stress experienced by the rural and low-educated populations because of unhealthy lifestyles and differences in the accessibility of health care and preventive measures.Therefore, it is obvious that intersectoral partnership should be ensured by using all possible means to reduce health inequalities and other major public health challenges.

HEALTH POLICY DEVELOPMENT IN LITHUANIA
Since 1990, the health sector of Lithuania has been undergoing an extensive reform aimed at creating a financially sustainable modern health care system able to provide high-quality services.In 1991, the Seimas (Parliament) of the Lithuanian Republic adopted the National Concept of Health (5) in which the health policy was formulated and priorities in the field were set, including the development of primary health care, introduction of the family doctor institution and foreseeing the structure of institutions within the health care system according to the primary, secondary and tertiary medical service provision levels.A strong emphasis was given to health promotion and disease prevention.The aforementioned concept has become a basis for the Lithuanian health policy formulation.In 1998, the Parliament of Lithuania approved the Lithuanian Health Programme for 1997-2010 (6).The main objectives of this programme were reduction of mortality and increasing life expectancy, the equity in health care and the quality of life.It has been emphasized that mortality rates can be reduced by targeting the most common causes of death -cardiovascular diseases, cancers, accidents, as well as reducing infant mortality.Equity in health care is understood as a practical possibility for every person to strive for the complete health potential and is related to equal possibilities to pursue health and reduce health differences.
The National Public Health Strategy was approved by the Lithuanian Government in 2001 (7).It is the main document aiming at modernization of the public health care system, development of the universal public health care potential and its adaptation to the increasing demands of the State.The Strategy identifies the main directions of the activities directed to improving the health and quality of life of the population.The National Public Health Strategy is a tool for implementing the National Health Concept, Lithuanian health policy, the European health policy "Health for All in the 21st Century" and requirements of the EU health policy.The objectives of the Strategy are health protection and health promotion throughout the whole individual's life span, reduction of mortality and morbidity rates, and prevention of diseases and injuries.A particular emphasis in the action plan of the implementation of the Strategy is given to strengthening public health at the municipal level, a broader dissemination of health information, increasing health literacy and community empowerment.The Lithuanian health reform is developing according to the Strategy, trying to take into account the current health, demographic, social and economic challenges.One of the important steps in implementing the National Public Health Strategy is strengthening public health at the municipal level through reorganization of the public health system and reallocating some services and functions.

DEVELOPMENT OF PUBLIC HEALTH CARE SYSTEM: RESPONSIBILITIES FOR PUBLIC HEALTH
The public health mandate is very broad, involving a multitude of concerns.It implies that public health cannot be ensured by one agency, professional group or governmental level, but it must be the responsibility of agencies at all levels.
The sanitary-epidemiological stations which had been functioning in Lithuania during the Soviet period were reorganized into hygiene centres in 1991.The last change was made in 1995 when hygiene centres were renamed to public health centres.In 2000, some of the public health centres' inspection functions were divorced to other institutions, such as the State Non-Food Products Inspectorate and State Food and Veterinary Service.The Ministry of Health established the State Public Health Service in 2000 in order to strengthen public health, prevent the hazards for health and inform the public about health protection and improvement possibilities.The objectives of the State Public Health Service were changed in 2006 when specialized public health institutions became accountable to the Ministry of Health.The main goal of the State Public Health Service is to ensure public health safety and to protect consumer rights in the sphere of public health safety and the quality of services by implementing the National health policy.The ten regional public health centres, established in each county of Lithuania, are accountable to the State Public Health Service.According to the latest amendments of the Law on Public Health, after reorganizing the Public Health Care Service, regional public health centres will be subordinated directly to the Ministry of Health.
The implementation of health policy is the responsibility of not only the central government, but also of the local authorities.The shift of responsibility often enables health to be placed somewhat higher on the political agenda.Many of the most successful health strategies have been developed at regional or local levels (8).Local governments of municipalities, with the help of local communities and non-governmental organizations, can reveal the prevailing problems of population health in their territories by monitoring the health of populations and thus identify the priorities and challenges that need to be tackled by implementing effective means of the well-being of people.Following the National Public Health Strategy and Action Plan adopted in 2006, the Ministry of Health prepared the legal acts and programmes that encourage local authorities to establish public health bureaus which have tapped the health promotion functions from regional public health centres.Amendments to the Law on Public Health were made in 2007, defining public health care at the state and local levels and settling that municipalities have to establish their local institutions -public health bureaus -or to sign an agreement with another municipality that has established such a bureau -on the local public health care.
One of the main public health care functions defined by the law mentioned above is the monitoring of public health for getting full-scale information on the population's health and prevailing risk factors, as well as planning and implementing local public health programmes.This also includes participation in and implementation of the national state public health programmes, health promotion, especially child and youth health promotion and education, dissemination of information and cooperation with other relevant State institutions, non-governmental organizations, communities, families, other sectors and partners.In 2006, first bureaus were started, and by the end of 2010 there were 32 municipal public health bureaus established in Lithuania; 19 more municipalities were providing public health services by agreements made with other municipalities that have established public health bureaus.Conclusively, 51 municipalities out of 60 have implemented public health care, and several more municipalities informed starting it from 2011 (9).This fast movement was mostly influenced by the successful implementation of the State Programme for Developing Public Health Care at Local Level (10).This document, approved by Government of the Republic of Lithuania, as its main purpose had to strengthen citizens' health by improving the accessibility of good-quality public health services in communities, making public health policy important at the local level, establishing public health bureaus, as well as improving the qualifications and skills of public health professionals.
According to the results of assessment of the State Programme for Developing Public Health Care at Local Level (11), in municipalities with public health bureaus established earliest, inhabitants have deeper and more accurate knowledge of health, a clearer understanding of public health, know about the public health bureau and its activities, feel its benefits, are more satisfied with the health education, training, participate more actively in various promotion activities.Implementation of the Programme has positively influenced peoples' health knowledge and behaviour.
One of the most important regulations in the State Programme for Developing Public Health Care at Local Level was concluding agreements between the Ministry of Health and municipalities and enabling extra funding from the state budget to municipalities through the Ministry of Health.An important issue for the development of public health at the local level is human resources; therefore, the number of public health bureaus and of specialists employed in these institutions have been increasing.The Ministry of Health has defined the mandatory positions that have to be maintained in the bureaus, as well as qualification requirements to hold them.The majority of specialists employed in public health bureaus are professionals in health monitoring, health promotion, health education, and child and youth public health.However, not all bureaus have all those mandatory positions or qualified professionals to hold them.Most of public health bureaus focus on health promotion and monitoring, although child and youth health care is in the spotlight and implemented by schools' public health professionals.Therefore, the decision was taken that these specialists should join the structure of a bureau, enabling a better coordination and quality of health monitoring and promotion at schools.Bureaus gather the required information from child health checks performed by family doctors.There are also good examples of practice in this field to design an electronic database which enables access of health professionals to health records, attendance of school and the reasons for absence.By the end of 2010, there were 470 specialists employed by the bureaus (9).
It is obvious that public health care at the local level is considered to be very complex.Public health bureaus are the major actors at the local (municipal) public health level.Their functions are presented in ) and others.Public health bureaus are involved also in municipality health programmes and local health programmes at schools.Therefore, these newly established institutions are becoming active leaders in public health at the local level, mobilizing synergies across the sectors and empowering local communities.The bureaus are working in close partnership with different sectors and institutions.They coordinate their functions with municipality health boards, municipality Doctor's Service, local community boards and are formal partners of schools involved in the development and implementation of the safety promotion, health education and disease prevention programmes.The bureaus closely collaborate with primary health care centres in the implementation of disease prevention programmes and health monitoring.
Public health bureaus are financed both from the national budget, Sickness Funds and the budgets of municipalities.According to the regulations, a municipality has to ensure funding for the local public health care in order to receive additional resources from the state budget.Some additional financing is obtained from international projects and programmes; however, it depends greatly on the activities of a bureau.Financial support from European funds is also an important aspect to mention.More than 4 million Euros (9,12) was recently allocated to improving the infrastructure of the bureaus.It is expected that funding from EU structural funds will undoubtedly enhance the knowledge and skills of health professionals and the quality of their work.

DISCUSSION: CHALLENGING STEPS FORWARD
Creating supportive environments for health is one of the five action areas determined by the World Health Organization in the 1986 Ottawa Charter for Health Promotion.The Jakarta Declaration on Leading Health Promotion into the Twenty-First Century went further in emphasizing the value of settings for implementing comprehensive strategies and providing an infrastructure for health promotion (13).Local government is ideally placed to develop and implement local policies and actions to address health problems and the broad range of the determinants that influence health.This involves actions in health monitoring, health education, disease prevention, safety promotion and others.Public health bureaus are institutions closest to local communities and have a potential enough for successful health promotion and education; their strategy is found in the answer to the question where health is being created: "Health is created and lived by people within the settings of their everyday life, where they learn, work, play and love.Health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members" (12; 14).
However, the establishment and activities of the bureaus depend greatly on political will.The foundations of the problems that are faced by the bureaus are associated with the fact that the functions and measures of municipal public health care which is supposed to be a priority in the development of public health care system in the country are not finally defined.The Lithuanian Public Health Law states that the Lithuanian National Public Health Strategy should be implemented through municipality health programmes.Further, implementation of the Lithuanian Health Programme at the local level is not well-defined and often fails to incorporate the effect of short-term strategies on the intermediate and long-term goals of the Programme and the Lithuanian National Public Health Strategy (15).To develop the quality assurance system of public health bureaus' activities is also an urgent issue.
On the negative side, public health bureaus still have a rather low visibility and unstable financing, which make their functioning challenging (12).The financing mechanisms of the bureaus are not fixed, and the criteria for planning and financing their activities are not commonly agreed upon and defined.However, the development of methodology for the need of allocations for concrete measures of public health care in municipalities is among governmental priorities (9,12).
The financial situation and funding of public health care in different municipalities is not uniform nor stable, and depends mainly on the priorities of the local policy (10).The experience of other countries clearly demonstrates that in sectors where health interests are compatible with the main sectoral interests, such as environmental, social or educational policies, gaining common ground is not so problematic as the win-win options can be found more easily, while in sectors where there are contrasting interests this is much more challenging and requires further work and pressure (16).This phenomenon becomes increasingly obvious in Lithuania.On the other hand, implementation of the integrated approach aimed at a broad range of health determinants, which are mainly influenced by factors beyond the health sector, is challenging due to economic constraints, lack of motivation and knowledge.
The newly established bureaus are encouraged to develop public health monitoring programmes, which are extremely important for identifying the further steps in health promotion at the local level and should serve as a background for planning further actions and developing strategies at the municipal level.Health monitoring, which is supposed to be one of the important activities of the bureaus, is still not sufficient for the reasons mentioned above as the activities of the bureaus are not always planned according to the major public health challenges in municipalities.
Further, activities of public health professionals employed at schools are challenging due to unfavorable traditional and cultural patterns caused by the systemic change in child health care at schools from personal health care provided by school nurses to modern public health care provided by public health professionals.The integration of school public health professionals in the structures of Public Health Bureaus improves their quality of services and coordination of activities.
The problems of human resources for public health bureaus have also to be addressed.Graduates from public health and health management university programmes should constitute the major part of the human resources of public health bureaus.However, many professionals presently employed in the bureaus still lack this education.
Above all, in overcoming these issues, much depends on the recently prepared amendments to the law on local self-government.If they are to come to life, the funding and stability problems of the bureaus will be mainly resolved, as the three main functions -public health promotion, monitoring of public health, and child health care -will be covered from the state budget.

CONCLUSIONS AND RECOMMENDATIONS: EXPANDING THE PUBLIC HEALTH AGENDA
1. Public health bureaus have set a broad mission, goals and priorities to promote municipal public health and wellbeing; these, in turn, are intended to inform the operational processes of local organizations.They aim at strengthening the planning role of local government in municipal public health by including evidence, community consultation and evaluation.Therefore, the development of public health bureaus provides means by which local governments, in partnership with the service providers, other stakeholders and the community within a municipality, can plan and implement public health services and programmes.
2. To strengthen the position of the public health bureaus in society, activities and benefits of these newly established institutions should be widely presented to the public.Concentration on the development priorities should be foreseen, e. g., on human resource development, infrastructure connections, sustainable financing mechanisms, as well as a strengthened focus on intersectoral cooperation and integrating public health into primary health care, strengthening the common areas of activities with family doctors and primary mental health.To ensure the sustainability of public health measures and activities, Lithuania needs continu-ous training and education of public health professionals capable of working at the community level.The strategies for future long-term activities and budgeting frameworks have to be developed.Public health care services provided by the public health bureaus, with detailed descriptions and nomenclatures, as well as evaluation procedures have to be further elaborated.Health needs assessment and the evaluation of the effectiveness of disease prevention and health promotion programmes should be a continuous process.Far more active efforts by public health bureaus to involve partners from other sectors are required.
3. In spite of the rather challenging beginning, public health bureaus begin playing a significant role in the implementation of health strategies and improving the health of the Lithuanian population.